Richard Mark Kirkner

The drastic drop in admissions for acute myocardial infarctions (AMI) during the COVID-19 pandemic in Italy has seen a parallel rise in MI fatality rates in those who do present to hospitals, according to a new report. This gives credence to suggestions that people have avoided hospitals during the pandemic despite life-threatening emergencies.

Salvatore De Rosa, MD, PhD, and colleagues reported their results in the European Heart Journal.

“These data return a frightening picture of about half of AMI patients not reaching out to the hospital at all, which will probably significantly increase mortality for AMI and bring with it a number of patients with post-MI heart failure, despite the fact that acute coronary syndrome management protocols were promptly implemented,” Dr. De Rosa, of Magna Graecia University in Catanzaro, Italy, and associates wrote.
 

Hospitalizations down

The study counted AMIs at 54 hospital coronary care units nationwide for the week of March 12-19, 2020, at the height of the coronavirus outbreak in northern Italy, and compared that with an equivalent week in 2019. The researchers reported 319 AMIs during the week in 2020, compared with 618 in the equivalent 2019 week, a 48% reduction (P < .001). Although the outbreak was worst in northern Italy, the decline in admissions occurred throughout the country.

An analysis of subtype determined the decline in the incidence of ST-segment elevation MI lagged significantly behind that of non-STEMI. STEMI declined from 268 in 2019 to 197 in 2020, a 27% reduction, while hospitalizations for non-STEMI went from 350 to 122, a 65% reduction.

The researchers also found substantial reductions in hospitalizations for heart failure, by 47%, and atrial fibrillation, by 53%. Incidentally, the mean age of atrial fibrillation patients was considerably younger in 2020: 64.6 vs. 70 years.
 

Death, complications up

AMI patients who managed to get to the hospital during the pandemic also had worse outcomes. Mortality for STEMI cases more than tripled, to 14% during the outbreak, compared with 4% in 2019 (P < .001) and complication rates increased by 80% to 19% (P = .025). Twenty-one STEMI patients were positive for COVID-19 and more than a quarter (29%) died, which was more than two and a half times the 12% death rate in non–COVID-19 STEMI patients.

Analysis of the STEMI group also found that the care gap for women with heart disease worsened significantly during the pandemic, as they comprised 20.3% of cases this year, compared with 25.4% before the pandemic. Also, the reduction in admissions for STEMI during the pandemic was statistically significant at 41% for women, but not for men at 18%.

Non-STEMI patients fared better overall than STEMI patients, but their outcomes also worsened during the pandemic. Non-STEMI patients were significantly less likely to have percutaneous coronary intervention during the pandemic than previously; the rate declined by 13%, from 77% to 66%. The non-STEMI mortality rate nearly doubled, although not statistically significantly, from 1.7% to 3.3%, whereas complication rates actually more than doubled, from 5.1% to 10.7%, a significant difference. Twelve (9.8%) of the non-STEMI patients were COVID-19 positive, but none died.
 

Trend extends beyond borders

Dr. De Rosa and colleagues noted that their findings are in line with studies that reported similar declines for STEMI interventions in the United States and Spain during the pandemic (J Am Coll Cardiol. 2020. doi: 10.1016/j.jacc.2020.04.011; REC Interv Cardiol. 2020. doi: 10.24875/RECIC.M20000120).

Additionally, a group at Kaiser Permanente in Northern California also reported a 50% decline in the incidence of AMI hospitalizations during the pandemic (N Engl J Med. 2020 May 19. doi: 10.1056/NEJMc2015630). Likewise, a study of aortic dissections in New York reported a sharp decline in procedures during the pandemic in the city, from 13 to 3 a month (J Am Coll Cardiol. 2020 May 15. doi: 10.1016/j.jacc.2020.05.022)

The researchers in Italy didn’t aim to determine the reasons for the decline in AMI hospitalizations, but Dr. De Rosa and colleagues speculated on the following explanations: Fear of contagion in response to media reports, concentration of resources to address COVID-19 may have engendered a sense to defer less urgent care among patients and health care systems, and a true reduction in acute cardiovascular disease because people under stay-at-home orders had low physical stress.

“The concern is fewer MIs most likely means people are dying at home or presenting later as this study suggests,” said Martha Gulati, MD, chief of cardiology at the University of Arizona, Phoenix, in interpreting the results of the Italian study.

That could be a result of a mixed message from the media about accessing health care during the pandemic. “What it suggests to a lot of us is that the media has transmitted this notion that hospitals are busy taking care of COVID-19 patients, but we never said don’t come to hospital if you’re having a heart attack,” Dr. Gulati said. “I think we created some sort of fear that patients if they didn’t have COVID-19 they didn’t want to bother physicians.”

Dr. Gulati, whose practice focuses on women with CVD, said the study’s findings that interventions in women dropped more precipitously than men were concerning. “We know already that women don’t do as well after a heart attack, compared to men, and now we see it worsen it even further when women aren’t presenting,” she said. “We’re worried that this is going to increase the gap.”

Dr. DeRosa and colleagues have no relevant financial relationships to disclose.

SOURCE: De Rosa S et al. Euro Heart J. 2020 May 15. doi: 10.1093/eurheartj/ehaa409.

The drastic drop in admissions for acute myocardial infarctions (AMI) during the COVID-19 pandemic in Italy has seen a parallel rise in MI fatality rates in those who do present to hospitals, according to a new report. This gives credence to suggestions that people have avoided hospitals during the pandemic despite life-threatening emergencies.

Salvatore De Rosa, MD, PhD, and colleagues reported their results in the European Heart Journal.

“These data return a frightening picture of about half of AMI patients not reaching out to the hospital at all, which will probably significantly increase mortality for AMI and bring with it a number of patients with post-MI heart failure, despite the fact that acute coronary syndrome management protocols were promptly implemented,” Dr. De Rosa, of Magna Graecia University in Catanzaro, Italy, and associates wrote.
 

Hospitalizations down

The study counted AMIs at 54 hospital coronary care units nationwide for the week of March 12-19, 2020, at the height of the coronavirus outbreak in northern Italy, and compared that with an equivalent week in 2019. The researchers reported 319 AMIs during the week in 2020, compared with 618 in the equivalent 2019 week, a 48% reduction (P < .001). Although the outbreak was worst in northern Italy, the decline in admissions occurred throughout the country.

An analysis of subtype determined the decline in the incidence of ST-segment elevation MI lagged significantly behind that of non-STEMI. STEMI declined from 268 in 2019 to 197 in 2020, a 27% reduction, while hospitalizations for non-STEMI went from 350 to 122, a 65% reduction.

The researchers also found substantial reductions in hospitalizations for heart failure, by 47%, and atrial fibrillation, by 53%. Incidentally, the mean age of atrial fibrillation patients was considerably younger in 2020: 64.6 vs. 70 years.
 

Death, complications up

AMI patients who managed to get to the hospital during the pandemic also had worse outcomes. Mortality for STEMI cases more than tripled, to 14% during the outbreak, compared with 4% in 2019 (P < .001) and complication rates increased by 80% to 19% (P = .025). Twenty-one STEMI patients were positive for COVID-19 and more than a quarter (29%) died, which was more than two and a half times the 12% death rate in non–COVID-19 STEMI patients.

Analysis of the STEMI group also found that the care gap for women with heart disease worsened significantly during the pandemic, as they comprised 20.3% of cases this year, compared with 25.4% before the pandemic. Also, the reduction in admissions for STEMI during the pandemic was statistically significant at 41% for women, but not for men at 18%.

Non-STEMI patients fared better overall than STEMI patients, but their outcomes also worsened during the pandemic. Non-STEMI patients were significantly less likely to have percutaneous coronary intervention during the pandemic than previously; the rate declined by 13%, from 77% to 66%. The non-STEMI mortality rate nearly doubled, although not statistically significantly, from 1.7% to 3.3%, whereas complication rates actually more than doubled, from 5.1% to 10.7%, a significant difference. Twelve (9.8%) of the non-STEMI patients were COVID-19 positive, but none died.
 

Trend extends beyond borders

Dr. De Rosa and colleagues noted that their findings are in line with studies that reported similar declines for STEMI interventions in the United States and Spain during the pandemic (J Am Coll Cardiol. 2020. doi: 10.1016/j.jacc.2020.04.011; REC Interv Cardiol. 2020. doi: 10.24875/RECIC.M20000120).

Additionally, a group at Kaiser Permanente in Northern California also reported a 50% decline in the incidence of AMI hospitalizations during the pandemic (N Engl J Med. 2020 May 19. doi: 10.1056/NEJMc2015630). Likewise, a study of aortic dissections in New York reported a sharp decline in procedures during the pandemic in the city, from 13 to 3 a month (J Am Coll Cardiol. 2020 May 15. doi: 10.1016/j.jacc.2020.05.022)

The researchers in Italy didn’t aim to determine the reasons for the decline in AMI hospitalizations, but Dr. De Rosa and colleagues speculated on the following explanations: Fear of contagion in response to media reports, concentration of resources to address COVID-19 may have engendered a sense to defer less urgent care among patients and health care systems, and a true reduction in acute cardiovascular disease because people under stay-at-home orders had low physical stress.

“The concern is fewer MIs most likely means people are dying at home or presenting later as this study suggests,” said Martha Gulati, MD, chief of cardiology at the University of Arizona, Phoenix, in interpreting the results of the Italian study.

That could be a result of a mixed message from the media about accessing health care during the pandemic. “What it suggests to a lot of us is that the media has transmitted this notion that hospitals are busy taking care of COVID-19 patients, but we never said don’t come to hospital if you’re having a heart attack,” Dr. Gulati said. “I think we created some sort of fear that patients if they didn’t have COVID-19 they didn’t want to bother physicians.”

Dr. Gulati, whose practice focuses on women with CVD, said the study’s findings that interventions in women dropped more precipitously than men were concerning. “We know already that women don’t do as well after a heart attack, compared to men, and now we see it worsen it even further when women aren’t presenting,” she said. “We’re worried that this is going to increase the gap.”

Dr. DeRosa and colleagues have no relevant financial relationships to disclose.

SOURCE: De Rosa S et al. Euro Heart J. 2020 May 15. doi: 10.1093/eurheartj/ehaa409.

The drastic drop in admissions for acute myocardial infarctions (AMI) during the COVID-19 pandemic in Italy has seen a parallel rise in MI fatality rates in those who do present to hospitals, according to a new report. This gives credence to suggestions that people have avoided hospitals during the pandemic despite life-threatening emergencies.

Salvatore De Rosa, MD, PhD, and colleagues reported their results in the European Heart Journal.

“These data return a frightening picture of about half of AMI patients not reaching out to the hospital at all, which will probably significantly increase mortality for AMI and bring with it a number of patients with post-MI heart failure, despite the fact that acute coronary syndrome management protocols were promptly implemented,” Dr. De Rosa, of Magna Graecia University in Catanzaro, Italy, and associates wrote.
 

Hospitalizations down

The study counted AMIs at 54 hospital coronary care units nationwide for the week of March 12-19, 2020, at the height of the coronavirus outbreak in northern Italy, and compared that with an equivalent week in 2019. The researchers reported 319 AMIs during the week in 2020, compared with 618 in the equivalent 2019 week, a 48% reduction (P < .001). Although the outbreak was worst in northern Italy, the decline in admissions occurred throughout the country.

An analysis of subtype determined the decline in the incidence of ST-segment elevation MI lagged significantly behind that of non-STEMI. STEMI declined from 268 in 2019 to 197 in 2020, a 27% reduction, while hospitalizations for non-STEMI went from 350 to 122, a 65% reduction.

The researchers also found substantial reductions in hospitalizations for heart failure, by 47%, and atrial fibrillation, by 53%. Incidentally, the mean age of atrial fibrillation patients was considerably younger in 2020: 64.6 vs. 70 years.
 

Death, complications up

AMI patients who managed to get to the hospital during the pandemic also had worse outcomes. Mortality for STEMI cases more than tripled, to 14% during the outbreak, compared with 4% in 2019 (P < .001) and complication rates increased by 80% to 19% (P = .025). Twenty-one STEMI patients were positive for COVID-19 and more than a quarter (29%) died, which was more than two and a half times the 12% death rate in non–COVID-19 STEMI patients.

Analysis of the STEMI group also found that the care gap for women with heart disease worsened significantly during the pandemic, as they comprised 20.3% of cases this year, compared with 25.4% before the pandemic. Also, the reduction in admissions for STEMI during the pandemic was statistically significant at 41% for women, but not for men at 18%.

Non-STEMI patients fared better overall than STEMI patients, but their outcomes also worsened during the pandemic. Non-STEMI patients were significantly less likely to have percutaneous coronary intervention during the pandemic than previously; the rate declined by 13%, from 77% to 66%. The non-STEMI mortality rate nearly doubled, although not statistically significantly, from 1.7% to 3.3%, whereas complication rates actually more than doubled, from 5.1% to 10.7%, a significant difference. Twelve (9.8%) of the non-STEMI patients were COVID-19 positive, but none died.
 

Trend extends beyond borders

Dr. De Rosa and colleagues noted that their findings are in line with studies that reported similar declines for STEMI interventions in the United States and Spain during the pandemic (J Am Coll Cardiol. 2020. doi: 10.1016/j.jacc.2020.04.011; REC Interv Cardiol. 2020. doi: 10.24875/RECIC.M20000120).

Additionally, a group at Kaiser Permanente in Northern California also reported a 50% decline in the incidence of AMI hospitalizations during the pandemic (N Engl J Med. 2020 May 19. doi: 10.1056/NEJMc2015630). Likewise, a study of aortic dissections in New York reported a sharp decline in procedures during the pandemic in the city, from 13 to 3 a month (J Am Coll Cardiol. 2020 May 15. doi: 10.1016/j.jacc.2020.05.022)

The researchers in Italy didn’t aim to determine the reasons for the decline in AMI hospitalizations, but Dr. De Rosa and colleagues speculated on the following explanations: Fear of contagion in response to media reports, concentration of resources to address COVID-19 may have engendered a sense to defer less urgent care among patients and health care systems, and a true reduction in acute cardiovascular disease because people under stay-at-home orders had low physical stress.

“The concern is fewer MIs most likely means people are dying at home or presenting later as this study suggests,” said Martha Gulati, MD, chief of cardiology at the University of Arizona, Phoenix, in interpreting the results of the Italian study.

That could be a result of a mixed message from the media about accessing health care during the pandemic. “What it suggests to a lot of us is that the media has transmitted this notion that hospitals are busy taking care of COVID-19 patients, but we never said don’t come to hospital if you’re having a heart attack,” Dr. Gulati said. “I think we created some sort of fear that patients if they didn’t have COVID-19 they didn’t want to bother physicians.”

Dr. Gulati, whose practice focuses on women with CVD, said the study’s findings that interventions in women dropped more precipitously than men were concerning. “We know already that women don’t do as well after a heart attack, compared to men, and now we see it worsen it even further when women aren’t presenting,” she said. “We’re worried that this is going to increase the gap.”

Dr. DeRosa and colleagues have no relevant financial relationships to disclose.

SOURCE: De Rosa S et al. Euro Heart J. 2020 May 15. doi: 10.1093/eurheartj/ehaa409.

Two reports of chilblain-like lesions in children suspected of having COVID-19 in Spain and Italy have been published, joining other recent reports of such cases in the United States and elsewhere.

These symptoms should be considered a sign of infection with the virus, but the symptoms themselves typically don’t require treatment, according to the authors of the two new reports, from hospitals in Milan and Madrid, published in Pediatric Dermatology.

In the first study, Cristiana Colonna, MD, and colleagues at Hospital Maggiore Polyclinic in Milan described four cases of chilblain-like lesions in children ages 5-11 years with mild COVID-19 symptoms.

In the second, David Andina, MD, and colleagues in the ED and the departments of dermatology and pathology at the Child Jesus University Children’s Hospital in Madrid published a retrospective study of 22 cases in children and adolescents ages 6-17 years who reported to the hospital ED from April 6 to 17, the peak of the pandemic in Madrid.

In all four of the Milan cases, the skin lesions appeared several days after the onset of COVID-19 symptoms, although all four patients initially tested negative for COVID-19. However, Dr. Colonna and colleagues wrote that, “given the fact that the sensitivity and specificity of both nasopharyngeal swabs and antibody tests for COVID-19 (when available) are not 100% reliable, the question of the origin of these strange chilblain-like lesions is still elusive.” Until further studies are available, they emphasized that clinicians should be “alert to the presentation of chilblain-like findings” in children with mild symptoms “as a possible sign of COVID-19 infection.”

All the patients had lesions on their feet or toes, and a 5-year-old boy also had lesions on the right hand. One patient, an 11-year-old girl, had a biopsy that revealed dense lymphocytic perivascular cuffing and periadnexal infiltration.

“The finding of an elevated d-dimer in one of our patients, along with the clinical features suggestive of a vasoocclusive phenomenon, supports consideration of laboratory evaluation for coagulation defects in asymptomatic or mildly symptomatic children with acrovasculitis-like findings,” Dr. Colonna and colleagues wrote. None of the four cases in Milan required treatment, with three cases resolving within 5 days.

Like the Milan cases, all 22 patients in the Madrid series had foot or toe lesions and three had lesions on the fingers. This larger series also reported more detailed symptoms about the lesions: pruritus in nine patients (41%) and mild pain in seven (32%). A total of 10 patients had systemic symptoms of COVID-19, predominantly cough and rhinorrhea in 9 patients (41%), but 2 (9%) had abdominal pain and diarrhea. These symptoms, the authors said, appeared a median of 14 days (range, 1-28 days) before they developed chilblains.

A total of 19 patients were tested for COVID-19, but only 1 was positive.

This retrospective study also included contact information, with one patient having household contact with a single confirmed case of COVID-19; 12 patients recalled household contact who were considered probable cases of COVID-19, with respiratory symptoms.

Skin biopsies were obtained from the acral lesions in six patients, all showing similar results, although with varying degrees of intensity. All biopsies showed features of lymphocytic vasculopathy. Some cases showed mild dermal and perieccrine mucinosis, lymphocytic eccrine hidradenitis, vascular ectasia, red cell extravasation and focal thrombosis described as “mostly confined to scattered papillary dermal capillaries, but also in vessels of the reticular dermis.”

The only treatments Dr. Andina and colleagues reported were oral analgesics for pain and oral antihistamines for pruritus when needed. One patient was given topical corticosteroids and another a short course of oral steroids, both for erythema multiforme.

Dr. Andina and colleagues wrote that the skin lesions in these patients “were unequivocally categorized as chilblains, both clinically and histopathologically,” and, after 7-10 days, began to fade. None of the patients had complications, and had an “excellent outcome,” they noted.

Dr. Colonna and colleagues had no conflicts of interest to declare. Dr. Andina and colleagues provided no disclosure statement.

SOURCES: Colonna C et al. Ped Derm. 2020 May 6. doi: 10.1111/pde.14210; Andina D et al. Ped Derm. 2020 May 9. doi: 10.1111/pde.14215.

Two reports of chilblain-like lesions in children suspected of having COVID-19 in Spain and Italy have been published, joining other recent reports of such cases in the United States and elsewhere.

These symptoms should be considered a sign of infection with the virus, but the symptoms themselves typically don’t require treatment, according to the authors of the two new reports, from hospitals in Milan and Madrid, published in Pediatric Dermatology.

In the first study, Cristiana Colonna, MD, and colleagues at Hospital Maggiore Polyclinic in Milan described four cases of chilblain-like lesions in children ages 5-11 years with mild COVID-19 symptoms.

In the second, David Andina, MD, and colleagues in the ED and the departments of dermatology and pathology at the Child Jesus University Children’s Hospital in Madrid published a retrospective study of 22 cases in children and adolescents ages 6-17 years who reported to the hospital ED from April 6 to 17, the peak of the pandemic in Madrid.

In all four of the Milan cases, the skin lesions appeared several days after the onset of COVID-19 symptoms, although all four patients initially tested negative for COVID-19. However, Dr. Colonna and colleagues wrote that, “given the fact that the sensitivity and specificity of both nasopharyngeal swabs and antibody tests for COVID-19 (when available) are not 100% reliable, the question of the origin of these strange chilblain-like lesions is still elusive.” Until further studies are available, they emphasized that clinicians should be “alert to the presentation of chilblain-like findings” in children with mild symptoms “as a possible sign of COVID-19 infection.”

All the patients had lesions on their feet or toes, and a 5-year-old boy also had lesions on the right hand. One patient, an 11-year-old girl, had a biopsy that revealed dense lymphocytic perivascular cuffing and periadnexal infiltration.

“The finding of an elevated d-dimer in one of our patients, along with the clinical features suggestive of a vasoocclusive phenomenon, supports consideration of laboratory evaluation for coagulation defects in asymptomatic or mildly symptomatic children with acrovasculitis-like findings,” Dr. Colonna and colleagues wrote. None of the four cases in Milan required treatment, with three cases resolving within 5 days.

Like the Milan cases, all 22 patients in the Madrid series had foot or toe lesions and three had lesions on the fingers. This larger series also reported more detailed symptoms about the lesions: pruritus in nine patients (41%) and mild pain in seven (32%). A total of 10 patients had systemic symptoms of COVID-19, predominantly cough and rhinorrhea in 9 patients (41%), but 2 (9%) had abdominal pain and diarrhea. These symptoms, the authors said, appeared a median of 14 days (range, 1-28 days) before they developed chilblains.

A total of 19 patients were tested for COVID-19, but only 1 was positive.

This retrospective study also included contact information, with one patient having household contact with a single confirmed case of COVID-19; 12 patients recalled household contact who were considered probable cases of COVID-19, with respiratory symptoms.

Skin biopsies were obtained from the acral lesions in six patients, all showing similar results, although with varying degrees of intensity. All biopsies showed features of lymphocytic vasculopathy. Some cases showed mild dermal and perieccrine mucinosis, lymphocytic eccrine hidradenitis, vascular ectasia, red cell extravasation and focal thrombosis described as “mostly confined to scattered papillary dermal capillaries, but also in vessels of the reticular dermis.”

The only treatments Dr. Andina and colleagues reported were oral analgesics for pain and oral antihistamines for pruritus when needed. One patient was given topical corticosteroids and another a short course of oral steroids, both for erythema multiforme.

Dr. Andina and colleagues wrote that the skin lesions in these patients “were unequivocally categorized as chilblains, both clinically and histopathologically,” and, after 7-10 days, began to fade. None of the patients had complications, and had an “excellent outcome,” they noted.

Dr. Colonna and colleagues had no conflicts of interest to declare. Dr. Andina and colleagues provided no disclosure statement.

SOURCES: Colonna C et al. Ped Derm. 2020 May 6. doi: 10.1111/pde.14210; Andina D et al. Ped Derm. 2020 May 9. doi: 10.1111/pde.14215.

Two reports of chilblain-like lesions in children suspected of having COVID-19 in Spain and Italy have been published, joining other recent reports of such cases in the United States and elsewhere.

These symptoms should be considered a sign of infection with the virus, but the symptoms themselves typically don’t require treatment, according to the authors of the two new reports, from hospitals in Milan and Madrid, published in Pediatric Dermatology.

In the first study, Cristiana Colonna, MD, and colleagues at Hospital Maggiore Polyclinic in Milan described four cases of chilblain-like lesions in children ages 5-11 years with mild COVID-19 symptoms.

In the second, David Andina, MD, and colleagues in the ED and the departments of dermatology and pathology at the Child Jesus University Children’s Hospital in Madrid published a retrospective study of 22 cases in children and adolescents ages 6-17 years who reported to the hospital ED from April 6 to 17, the peak of the pandemic in Madrid.

In all four of the Milan cases, the skin lesions appeared several days after the onset of COVID-19 symptoms, although all four patients initially tested negative for COVID-19. However, Dr. Colonna and colleagues wrote that, “given the fact that the sensitivity and specificity of both nasopharyngeal swabs and antibody tests for COVID-19 (when available) are not 100% reliable, the question of the origin of these strange chilblain-like lesions is still elusive.” Until further studies are available, they emphasized that clinicians should be “alert to the presentation of chilblain-like findings” in children with mild symptoms “as a possible sign of COVID-19 infection.”

All the patients had lesions on their feet or toes, and a 5-year-old boy also had lesions on the right hand. One patient, an 11-year-old girl, had a biopsy that revealed dense lymphocytic perivascular cuffing and periadnexal infiltration.

“The finding of an elevated d-dimer in one of our patients, along with the clinical features suggestive of a vasoocclusive phenomenon, supports consideration of laboratory evaluation for coagulation defects in asymptomatic or mildly symptomatic children with acrovasculitis-like findings,” Dr. Colonna and colleagues wrote. None of the four cases in Milan required treatment, with three cases resolving within 5 days.

Like the Milan cases, all 22 patients in the Madrid series had foot or toe lesions and three had lesions on the fingers. This larger series also reported more detailed symptoms about the lesions: pruritus in nine patients (41%) and mild pain in seven (32%). A total of 10 patients had systemic symptoms of COVID-19, predominantly cough and rhinorrhea in 9 patients (41%), but 2 (9%) had abdominal pain and diarrhea. These symptoms, the authors said, appeared a median of 14 days (range, 1-28 days) before they developed chilblains.

A total of 19 patients were tested for COVID-19, but only 1 was positive.

This retrospective study also included contact information, with one patient having household contact with a single confirmed case of COVID-19; 12 patients recalled household contact who were considered probable cases of COVID-19, with respiratory symptoms.

Skin biopsies were obtained from the acral lesions in six patients, all showing similar results, although with varying degrees of intensity. All biopsies showed features of lymphocytic vasculopathy. Some cases showed mild dermal and perieccrine mucinosis, lymphocytic eccrine hidradenitis, vascular ectasia, red cell extravasation and focal thrombosis described as “mostly confined to scattered papillary dermal capillaries, but also in vessels of the reticular dermis.”

The only treatments Dr. Andina and colleagues reported were oral analgesics for pain and oral antihistamines for pruritus when needed. One patient was given topical corticosteroids and another a short course of oral steroids, both for erythema multiforme.

Dr. Andina and colleagues wrote that the skin lesions in these patients “were unequivocally categorized as chilblains, both clinically and histopathologically,” and, after 7-10 days, began to fade. None of the patients had complications, and had an “excellent outcome,” they noted.

Dr. Colonna and colleagues had no conflicts of interest to declare. Dr. Andina and colleagues provided no disclosure statement.

SOURCES: Colonna C et al. Ped Derm. 2020 May 6. doi: 10.1111/pde.14210; Andina D et al. Ped Derm. 2020 May 9. doi: 10.1111/pde.14215.

With little evidence available on the role of bronchoscopy during the COVID-19 pandemic, an expert panel has published a guideline recommending its spare use in COVID-19 patients and those with suspected COVID-19 infection.

The panel stated that in the context of the COVID-19 crisis, bronchoscopy and other aerosol-generating procedures put health care workers (HCWs) at particularly high risk of exposure and infection. They recommended deferring bronchoscopy in nonurgent cases, and advised practitioners to wear personal protective equipment when performing bronchoscopy, even on asymptomatic patients.

The guideline and expert panel report have been published online in the journal Chest. CHEST and the American Association for Bronchology and Interventional Pulmonology participated in selecting the 14 panelists. “The recommendation and suggestions outlined in this document were specifically created to address what were felt to be clinically common and urgent questions that frontline clinicians are likely to face,” wrote lead author and panel cochair Momen M. Wahidi, MD, MBA, of Duke University, Durham, N.C., and colleagues.

Only one of the six recommendations is based on graded evidence; the remainder are ungraded consensus-based statements. The guideline consists of the following recommendations for performing or using bronchoscopy:

• HCWs in the procedure or recovery rooms should wear either an N-95 respirator or powered air-purifying respirator (PAPR) when performing bronchoscopy on patients suspected or confirmed to have COVID-19. They should wear personal protective equipment (PPE) that includes a face shield, gown, and gloves, and they should discard N-95 respirators after performing bronchoscopy.
• A nasopharyngeal specimen in COVID-19 suspects should be obtained before performing bronchoscopy. If the patient has severe or progressive disease that requires intubation but an additional specimen is needed to confirm COVID-19 or another diagnosis that could change the treatment course, an option would be lower-respiratory specimen from the endotracheal aspirate or bronchoscopy with bronchoalveolar lavage.
• HCWs should wear an N-95 or PAPR when doing bronchoscopy on asymptomatic patients in an area with community spread of COVID-19 – again, with the PPE designated in the first recommendation.
• Test for COVID-19 before doing bronchoscopy on asymptomatic patients. Defer nonurgent bronchoscopy if the test is positive. If it’s negative, follow the recommendations regarding respirators and PPE when doing bronchoscopy.
• Perform timely bronchoscopy when indicated even in an area with known community spread of COVID-19. This is the only graded recommendation among the six (Grade 2C) and may be the most nuanced. Local teams should develop strategies for using bronchoscopy in their setting, taking into account local resources and availability of PPE, and they should send noninfected cancer patients from resource-depleted hospitals to other centers.
• Base the timing of bronchoscopy in patients recovering after COVID-19 on the indication for the procedure, disease severity, and time duration since symptoms resolved. The recommendation noted that the exact timing is still unknown, but that a wait of at least 30 days after symptoms recede is “reasonable.”

The expert panel added a noteworthy caveat to the recommendations. “We would like to stress that these protective strategies can be rendered completely ineffective if proper training on donning and doffing is not provided to HCW,” Dr. Wahidi and colleagues wrote. “Proper personnel instruction and practice for wearing PPE should receive as much attention by health facilities as the chosen strategy for protection.”

Dr. Wahidi and colleagues have no financial relationships to disclose.

SOURCE: Wahidi MM et al. CHEST. 2020 Apr 30. doi: 10.1016/j.chest.2020.04.036.

With little evidence available on the role of bronchoscopy during the COVID-19 pandemic, an expert panel has published a guideline recommending its spare use in COVID-19 patients and those with suspected COVID-19 infection.

The panel stated that in the context of the COVID-19 crisis, bronchoscopy and other aerosol-generating procedures put health care workers (HCWs) at particularly high risk of exposure and infection. They recommended deferring bronchoscopy in nonurgent cases, and advised practitioners to wear personal protective equipment when performing bronchoscopy, even on asymptomatic patients.

The guideline and expert panel report have been published online in the journal Chest. CHEST and the American Association for Bronchology and Interventional Pulmonology participated in selecting the 14 panelists. “The recommendation and suggestions outlined in this document were specifically created to address what were felt to be clinically common and urgent questions that frontline clinicians are likely to face,” wrote lead author and panel cochair Momen M. Wahidi, MD, MBA, of Duke University, Durham, N.C., and colleagues.

Only one of the six recommendations is based on graded evidence; the remainder are ungraded consensus-based statements. The guideline consists of the following recommendations for performing or using bronchoscopy:

• HCWs in the procedure or recovery rooms should wear either an N-95 respirator or powered air-purifying respirator (PAPR) when performing bronchoscopy on patients suspected or confirmed to have COVID-19. They should wear personal protective equipment (PPE) that includes a face shield, gown, and gloves, and they should discard N-95 respirators after performing bronchoscopy.
• A nasopharyngeal specimen in COVID-19 suspects should be obtained before performing bronchoscopy. If the patient has severe or progressive disease that requires intubation but an additional specimen is needed to confirm COVID-19 or another diagnosis that could change the treatment course, an option would be lower-respiratory specimen from the endotracheal aspirate or bronchoscopy with bronchoalveolar lavage.
• HCWs should wear an N-95 or PAPR when doing bronchoscopy on asymptomatic patients in an area with community spread of COVID-19 – again, with the PPE designated in the first recommendation.
• Test for COVID-19 before doing bronchoscopy on asymptomatic patients. Defer nonurgent bronchoscopy if the test is positive. If it’s negative, follow the recommendations regarding respirators and PPE when doing bronchoscopy.
• Perform timely bronchoscopy when indicated even in an area with known community spread of COVID-19. This is the only graded recommendation among the six (Grade 2C) and may be the most nuanced. Local teams should develop strategies for using bronchoscopy in their setting, taking into account local resources and availability of PPE, and they should send noninfected cancer patients from resource-depleted hospitals to other centers.
• Base the timing of bronchoscopy in patients recovering after COVID-19 on the indication for the procedure, disease severity, and time duration since symptoms resolved. The recommendation noted that the exact timing is still unknown, but that a wait of at least 30 days after symptoms recede is “reasonable.”

The expert panel added a noteworthy caveat to the recommendations. “We would like to stress that these protective strategies can be rendered completely ineffective if proper training on donning and doffing is not provided to HCW,” Dr. Wahidi and colleagues wrote. “Proper personnel instruction and practice for wearing PPE should receive as much attention by health facilities as the chosen strategy for protection.”

Dr. Wahidi and colleagues have no financial relationships to disclose.

SOURCE: Wahidi MM et al. CHEST. 2020 Apr 30. doi: 10.1016/j.chest.2020.04.036.

With little evidence available on the role of bronchoscopy during the COVID-19 pandemic, an expert panel has published a guideline recommending its spare use in COVID-19 patients and those with suspected COVID-19 infection.

The panel stated that in the context of the COVID-19 crisis, bronchoscopy and other aerosol-generating procedures put health care workers (HCWs) at particularly high risk of exposure and infection. They recommended deferring bronchoscopy in nonurgent cases, and advised practitioners to wear personal protective equipment when performing bronchoscopy, even on asymptomatic patients.

The guideline and expert panel report have been published online in the journal Chest. CHEST and the American Association for Bronchology and Interventional Pulmonology participated in selecting the 14 panelists. “The recommendation and suggestions outlined in this document were specifically created to address what were felt to be clinically common and urgent questions that frontline clinicians are likely to face,” wrote lead author and panel cochair Momen M. Wahidi, MD, MBA, of Duke University, Durham, N.C., and colleagues.

Only one of the six recommendations is based on graded evidence; the remainder are ungraded consensus-based statements. The guideline consists of the following recommendations for performing or using bronchoscopy:

• HCWs in the procedure or recovery rooms should wear either an N-95 respirator or powered air-purifying respirator (PAPR) when performing bronchoscopy on patients suspected or confirmed to have COVID-19. They should wear personal protective equipment (PPE) that includes a face shield, gown, and gloves, and they should discard N-95 respirators after performing bronchoscopy.
• A nasopharyngeal specimen in COVID-19 suspects should be obtained before performing bronchoscopy. If the patient has severe or progressive disease that requires intubation but an additional specimen is needed to confirm COVID-19 or another diagnosis that could change the treatment course, an option would be lower-respiratory specimen from the endotracheal aspirate or bronchoscopy with bronchoalveolar lavage.
• HCWs should wear an N-95 or PAPR when doing bronchoscopy on asymptomatic patients in an area with community spread of COVID-19 – again, with the PPE designated in the first recommendation.
• Test for COVID-19 before doing bronchoscopy on asymptomatic patients. Defer nonurgent bronchoscopy if the test is positive. If it’s negative, follow the recommendations regarding respirators and PPE when doing bronchoscopy.
• Perform timely bronchoscopy when indicated even in an area with known community spread of COVID-19. This is the only graded recommendation among the six (Grade 2C) and may be the most nuanced. Local teams should develop strategies for using bronchoscopy in their setting, taking into account local resources and availability of PPE, and they should send noninfected cancer patients from resource-depleted hospitals to other centers.
• Base the timing of bronchoscopy in patients recovering after COVID-19 on the indication for the procedure, disease severity, and time duration since symptoms resolved. The recommendation noted that the exact timing is still unknown, but that a wait of at least 30 days after symptoms recede is “reasonable.”

The expert panel added a noteworthy caveat to the recommendations. “We would like to stress that these protective strategies can be rendered completely ineffective if proper training on donning and doffing is not provided to HCW,” Dr. Wahidi and colleagues wrote. “Proper personnel instruction and practice for wearing PPE should receive as much attention by health facilities as the chosen strategy for protection.”

Dr. Wahidi and colleagues have no financial relationships to disclose.

SOURCE: Wahidi MM et al. CHEST. 2020 Apr 30. doi: 10.1016/j.chest.2020.04.036.

Adolescents with obesity, type 2 diabetes, and systolic hypertension show accelerated development of signs of atherosclerosis significantly greater than their normal-weight peers, according to a longitudinal study published online in the Journal of the American Heart Association.

The study evaluated 448 adolescents over 5 years for changes in a variety of metrics to determine changes in arterial structure, including carotid intima media thickness (cIMT), carotid-femoral pulse-wave velocity (PWV), and augmentation index (Aix). The average age of the study group was 17.6 years. The three study groups broke down accordingly: 141 with normal weight, 156 with obesity, and 151 with type 2 diabetes. Patients were evaluated at baseline and 5 years later.

“The presence of obesity and especially type 2 diabetes in adolescents accelerates the early vascular aging process associated with several key risk factors,” wrote Justin R. Ryder, PhD, an assistant professor of pediatrics at the University of Minnesota, Minneapolis, and colleagues.

The researchers also noted that systolic hypertension was associated with changes in cIMT and arterial stiffness comparable to obesity and diabetes. “These data add further evidence underscoring the importance of efforts targeting prevention and treatment of obesity, type 2 diabetes, and elevated blood pressure among youth, with a goal of delaying and/or preventing the progression of early vascular aging,” Dr. Ryder and colleagues wrote.

Obese patients, when compared with normal-weight participants, had the following average increases: common cIMT by 0.05 mm, bulb cIMT by 0.02 mm, internal cIMT by 0.03 mm, and PWV carotid-femoral by 0.38 m/sec, all statistically significant differences. Patients with diabetes, compared with normal-weight participants, registered the following average increases: common cIMT by 0.05 mm, bulb cIMT by 0.06 mm, internal cIMT by 0.04 mm, Aix by 4.67%, and PWV carotid-femoral by 0.74 m/sec. All differences were highly significant at P less than .001.

The results also showed that higher baseline systolic blood pressure was associated with significantly greater average increases in the following factors: common cIMT by 0.007 mm, bulb cIMT by 0.009 mm, internal cIMT by 0.008 mm, and PWV carotid-femoral by 0.66 m/sec.

Drilling down into the data, the study reported that males had greater increases in bulb cIMT and incremental elastic modulus as well as reduced Aix, compared with females. Nonwhites also had greater increases in bulb cIMT than did whites. Age was associated with greater increases in bulb and internal cIMT and Aix.

“Our data support the concept that male sex is an independent and primary risk factor for accelerated early vascular aging,” Dr. Ryder and colleagues wrote. The study also determined that type 2 diabetes is a more prominent risk factor than obesity for early vascular aging.

The size of the study population, specifically adolescents with diabetes, is a study strength, Dr. Ryder and colleagues noted. Other strengths they pointed to are the 5-year duration and the robust panel of noninvasive measures, although not using hard cardiovascular outcomes is an acknowledged limitation.

“It should also be noted that many of the youth with type 2 diabetes were on medications for glycemic control, lipids, and/or blood pressure regulation,” Dr. Ryder and colleagues wrote. “Despite this, the vascular profiles worsened over time.”

The study showed “a really significant change” in the carotid anatomy in adolescents with obesity and type 2 diabetes over 5 years, Robert Eckel, MD, professor at the University of Colorado Anschutz Medical Campus, Aurora, said in an interview. “Notably, the PWV is not just anatomy; now we’re talking about function. In other words, the augmentation index and PWV will assess the compliance of the artery.”

The findings suggest that atherosclerosis begins with thickening of the arterial walls. “The question is, is thickness reversible?” Dr. Eckel said. “It’s probably not very reversible, so these are early changes that ultimately in the middle years or latter years are associated with major cardiovascular disease.”

They key lesson from the study, Dr. Eckel noted, is to “prevent obesity. If you prevent obesity in the teenage years, you basically prevent diabetes.”

Dr. Ryder disclosed receiving support from Boehringer Ingelheim in the form of drug/placebo. The National Institutes of Health provided funding. Dr. Eckel has no relevant relationships to disclose.

SOURCE: Ryder JR et al. J Am Heart Assoc. 2020 May 6:e014891. doi: 10.1161/JAHA.119.014891.

Adolescents with obesity, type 2 diabetes, and systolic hypertension show accelerated development of signs of atherosclerosis significantly greater than their normal-weight peers, according to a longitudinal study published online in the Journal of the American Heart Association.

The study evaluated 448 adolescents over 5 years for changes in a variety of metrics to determine changes in arterial structure, including carotid intima media thickness (cIMT), carotid-femoral pulse-wave velocity (PWV), and augmentation index (Aix). The average age of the study group was 17.6 years. The three study groups broke down accordingly: 141 with normal weight, 156 with obesity, and 151 with type 2 diabetes. Patients were evaluated at baseline and 5 years later.

“The presence of obesity and especially type 2 diabetes in adolescents accelerates the early vascular aging process associated with several key risk factors,” wrote Justin R. Ryder, PhD, an assistant professor of pediatrics at the University of Minnesota, Minneapolis, and colleagues.

The researchers also noted that systolic hypertension was associated with changes in cIMT and arterial stiffness comparable to obesity and diabetes. “These data add further evidence underscoring the importance of efforts targeting prevention and treatment of obesity, type 2 diabetes, and elevated blood pressure among youth, with a goal of delaying and/or preventing the progression of early vascular aging,” Dr. Ryder and colleagues wrote.

Obese patients, when compared with normal-weight participants, had the following average increases: common cIMT by 0.05 mm, bulb cIMT by 0.02 mm, internal cIMT by 0.03 mm, and PWV carotid-femoral by 0.38 m/sec, all statistically significant differences. Patients with diabetes, compared with normal-weight participants, registered the following average increases: common cIMT by 0.05 mm, bulb cIMT by 0.06 mm, internal cIMT by 0.04 mm, Aix by 4.67%, and PWV carotid-femoral by 0.74 m/sec. All differences were highly significant at P less than .001.

The results also showed that higher baseline systolic blood pressure was associated with significantly greater average increases in the following factors: common cIMT by 0.007 mm, bulb cIMT by 0.009 mm, internal cIMT by 0.008 mm, and PWV carotid-femoral by 0.66 m/sec.

Drilling down into the data, the study reported that males had greater increases in bulb cIMT and incremental elastic modulus as well as reduced Aix, compared with females. Nonwhites also had greater increases in bulb cIMT than did whites. Age was associated with greater increases in bulb and internal cIMT and Aix.

“Our data support the concept that male sex is an independent and primary risk factor for accelerated early vascular aging,” Dr. Ryder and colleagues wrote. The study also determined that type 2 diabetes is a more prominent risk factor than obesity for early vascular aging.

The size of the study population, specifically adolescents with diabetes, is a study strength, Dr. Ryder and colleagues noted. Other strengths they pointed to are the 5-year duration and the robust panel of noninvasive measures, although not using hard cardiovascular outcomes is an acknowledged limitation.

“It should also be noted that many of the youth with type 2 diabetes were on medications for glycemic control, lipids, and/or blood pressure regulation,” Dr. Ryder and colleagues wrote. “Despite this, the vascular profiles worsened over time.”

The study showed “a really significant change” in the carotid anatomy in adolescents with obesity and type 2 diabetes over 5 years, Robert Eckel, MD, professor at the University of Colorado Anschutz Medical Campus, Aurora, said in an interview. “Notably, the PWV is not just anatomy; now we’re talking about function. In other words, the augmentation index and PWV will assess the compliance of the artery.”

The findings suggest that atherosclerosis begins with thickening of the arterial walls. “The question is, is thickness reversible?” Dr. Eckel said. “It’s probably not very reversible, so these are early changes that ultimately in the middle years or latter years are associated with major cardiovascular disease.”

They key lesson from the study, Dr. Eckel noted, is to “prevent obesity. If you prevent obesity in the teenage years, you basically prevent diabetes.”

Dr. Ryder disclosed receiving support from Boehringer Ingelheim in the form of drug/placebo. The National Institutes of Health provided funding. Dr. Eckel has no relevant relationships to disclose.

SOURCE: Ryder JR et al. J Am Heart Assoc. 2020 May 6:e014891. doi: 10.1161/JAHA.119.014891.

Adolescents with obesity, type 2 diabetes, and systolic hypertension show accelerated development of signs of atherosclerosis significantly greater than their normal-weight peers, according to a longitudinal study published online in the Journal of the American Heart Association.

The study evaluated 448 adolescents over 5 years for changes in a variety of metrics to determine changes in arterial structure, including carotid intima media thickness (cIMT), carotid-femoral pulse-wave velocity (PWV), and augmentation index (Aix). The average age of the study group was 17.6 years. The three study groups broke down accordingly: 141 with normal weight, 156 with obesity, and 151 with type 2 diabetes. Patients were evaluated at baseline and 5 years later.

“The presence of obesity and especially type 2 diabetes in adolescents accelerates the early vascular aging process associated with several key risk factors,” wrote Justin R. Ryder, PhD, an assistant professor of pediatrics at the University of Minnesota, Minneapolis, and colleagues.

The researchers also noted that systolic hypertension was associated with changes in cIMT and arterial stiffness comparable to obesity and diabetes. “These data add further evidence underscoring the importance of efforts targeting prevention and treatment of obesity, type 2 diabetes, and elevated blood pressure among youth, with a goal of delaying and/or preventing the progression of early vascular aging,” Dr. Ryder and colleagues wrote.

Obese patients, when compared with normal-weight participants, had the following average increases: common cIMT by 0.05 mm, bulb cIMT by 0.02 mm, internal cIMT by 0.03 mm, and PWV carotid-femoral by 0.38 m/sec, all statistically significant differences. Patients with diabetes, compared with normal-weight participants, registered the following average increases: common cIMT by 0.05 mm, bulb cIMT by 0.06 mm, internal cIMT by 0.04 mm, Aix by 4.67%, and PWV carotid-femoral by 0.74 m/sec. All differences were highly significant at P less than .001.

The results also showed that higher baseline systolic blood pressure was associated with significantly greater average increases in the following factors: common cIMT by 0.007 mm, bulb cIMT by 0.009 mm, internal cIMT by 0.008 mm, and PWV carotid-femoral by 0.66 m/sec.

Drilling down into the data, the study reported that males had greater increases in bulb cIMT and incremental elastic modulus as well as reduced Aix, compared with females. Nonwhites also had greater increases in bulb cIMT than did whites. Age was associated with greater increases in bulb and internal cIMT and Aix.

“Our data support the concept that male sex is an independent and primary risk factor for accelerated early vascular aging,” Dr. Ryder and colleagues wrote. The study also determined that type 2 diabetes is a more prominent risk factor than obesity for early vascular aging.

The size of the study population, specifically adolescents with diabetes, is a study strength, Dr. Ryder and colleagues noted. Other strengths they pointed to are the 5-year duration and the robust panel of noninvasive measures, although not using hard cardiovascular outcomes is an acknowledged limitation.

“It should also be noted that many of the youth with type 2 diabetes were on medications for glycemic control, lipids, and/or blood pressure regulation,” Dr. Ryder and colleagues wrote. “Despite this, the vascular profiles worsened over time.”

The study showed “a really significant change” in the carotid anatomy in adolescents with obesity and type 2 diabetes over 5 years, Robert Eckel, MD, professor at the University of Colorado Anschutz Medical Campus, Aurora, said in an interview. “Notably, the PWV is not just anatomy; now we’re talking about function. In other words, the augmentation index and PWV will assess the compliance of the artery.”

The findings suggest that atherosclerosis begins with thickening of the arterial walls. “The question is, is thickness reversible?” Dr. Eckel said. “It’s probably not very reversible, so these are early changes that ultimately in the middle years or latter years are associated with major cardiovascular disease.”

They key lesson from the study, Dr. Eckel noted, is to “prevent obesity. If you prevent obesity in the teenage years, you basically prevent diabetes.”

Dr. Ryder disclosed receiving support from Boehringer Ingelheim in the form of drug/placebo. The National Institutes of Health provided funding. Dr. Eckel has no relevant relationships to disclose.

SOURCE: Ryder JR et al. J Am Heart Assoc. 2020 May 6:e014891. doi: 10.1161/JAHA.119.014891.

Readily available and inexpensive noninvasive tests, when used in combination with liver markers obtained with the extra-large probe, can improve the ability to predict risk for decompensation and other adverse outcomes in obese and overweight patients with compensated advanced chronic liver disease (cACLD), according to study results reported in the upcoming issue of the journal Clinical Gastroenterology and Hepatology.

The retrospective study of 272 obese and overweight patients in Bern, Switzerland, and Montreal with cACLD is the first to fully assess the noninvasive marker of portal hypertension along with using the extra-large probe for controlled attenuation parameter (CAP) to determine risk, wrote Yuly Mendoza, MD, of the University of Bern and colleagues. Decompensation in cACLD carries a higher risk of death. The study noted that portal hypertension is a key driver of progression to decompensation, “and as such, it should be identified as soon as possible and treated as needed.”

“Prediction of prognosis in cACLD is challenging, and noninvasive tests are important tools for clinicians to avoid as much as possible the use of more invasive tests,” wrote Dr. Mendoza and colleagues. Based on the extra-large probe, 76% (n = 206) of study patients had metabolic syndrome, sometimes with other etiologies of liver disease, and 57% (n = 154) had cACLD because of nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH).

Twelve patients had decompensation and five developed severe bacterial infections.

“Readily available noninvasive tests can be used to identify obese or overweight patients with cACLD who are at increased risk for decompensation and severe bacterial infections,” wrote the researchers.

The study noted that obesity is a challenge for noninvasive tests and is a major limitation to liver stiffness measurement on transient elastography using the standard M probe. The XL probe has been specifically designed to overcome this challenge in obese patients, but it hasn’t been evaluated for the prediction of clinical decompensation in obese patients with cACLD.

This study claimed to provide further evidence that liver stiffness measurement in combination with noninvasive tests for liver stiffness measurement, spleen size/platelet count (LSPS), portal hypertension and portal hypertension risk score can help identify patients at risk for clinical decompensation and severe bacterial infections.

The study used average area under the receiving operator curve (AUC) to calculate the ability of the markers to distinguish risk, all with 95% confidence interval: 0.803 for liver stiffness measurement, 0.829 for portal hypertension risk score, and 0.845 for LSPS (P < .001). The markers showed an even better ability to differentiate between patients at risk for developing classical clinical decompensation in follow-up from those not at risk (all 95% CI): 0.848 for liver stiffness measurement, 0.881 for portal hypertension risk score, and 0.890 for LSPS (P < .001).

“The results of the present study validate the use of [extra-large] probe for liver stiffness measurement and CAP to stratify the risk of clinical decompensation and clinically relevant events in overweight/obese patients with cACLD, particularly in case of NAFLD/NASH etiology,” wrote Dr. Mendoza and colleagues.

All study participants were followed for at least 6 months, with a median of 17 months. Patients who developed decompensation or severe bacterial infections had slightly worse liver function (higher international normalized ratio and lower albumin), lower mean platelet count (117 vs. 179 x 10⁹/L; P < .001) and lower mean CAP (297 vs. 318 dBm; P = .030) than did patients who stayed compensated.

CAP above 220 dB/m was marginally associated with a lower risk of decompensation or severe bacterial infections on univariate analysis, as were elevated Model for End-Stage Liver Disease score, elevated Child Pugh score, low platelet count, low serum albumin, elevated serum bilirubin and increased liver stiffness measurement, LSPS, and portal hypertension risk scores.

Dr. Mendoza and colleagues have no relevant financial disclosures. The study received funding from the Swiss government.

SOURCE: Mendoza Y et al. Clin Gastroenterol Hepatol. 2020. doi: 10.1016/j.cgh.2020.04.018.

Readily available and inexpensive noninvasive tests, when used in combination with liver markers obtained with the extra-large probe, can improve the ability to predict risk for decompensation and other adverse outcomes in obese and overweight patients with compensated advanced chronic liver disease (cACLD), according to study results reported in the upcoming issue of the journal Clinical Gastroenterology and Hepatology.

The retrospective study of 272 obese and overweight patients in Bern, Switzerland, and Montreal with cACLD is the first to fully assess the noninvasive marker of portal hypertension along with using the extra-large probe for controlled attenuation parameter (CAP) to determine risk, wrote Yuly Mendoza, MD, of the University of Bern and colleagues. Decompensation in cACLD carries a higher risk of death. The study noted that portal hypertension is a key driver of progression to decompensation, “and as such, it should be identified as soon as possible and treated as needed.”

“Prediction of prognosis in cACLD is challenging, and noninvasive tests are important tools for clinicians to avoid as much as possible the use of more invasive tests,” wrote Dr. Mendoza and colleagues. Based on the extra-large probe, 76% (n = 206) of study patients had metabolic syndrome, sometimes with other etiologies of liver disease, and 57% (n = 154) had cACLD because of nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH).

Twelve patients had decompensation and five developed severe bacterial infections.

“Readily available noninvasive tests can be used to identify obese or overweight patients with cACLD who are at increased risk for decompensation and severe bacterial infections,” wrote the researchers.

The study noted that obesity is a challenge for noninvasive tests and is a major limitation to liver stiffness measurement on transient elastography using the standard M probe. The XL probe has been specifically designed to overcome this challenge in obese patients, but it hasn’t been evaluated for the prediction of clinical decompensation in obese patients with cACLD.

This study claimed to provide further evidence that liver stiffness measurement in combination with noninvasive tests for liver stiffness measurement, spleen size/platelet count (LSPS), portal hypertension and portal hypertension risk score can help identify patients at risk for clinical decompensation and severe bacterial infections.

The study used average area under the receiving operator curve (AUC) to calculate the ability of the markers to distinguish risk, all with 95% confidence interval: 0.803 for liver stiffness measurement, 0.829 for portal hypertension risk score, and 0.845 for LSPS (P < .001). The markers showed an even better ability to differentiate between patients at risk for developing classical clinical decompensation in follow-up from those not at risk (all 95% CI): 0.848 for liver stiffness measurement, 0.881 for portal hypertension risk score, and 0.890 for LSPS (P < .001).

“The results of the present study validate the use of [extra-large] probe for liver stiffness measurement and CAP to stratify the risk of clinical decompensation and clinically relevant events in overweight/obese patients with cACLD, particularly in case of NAFLD/NASH etiology,” wrote Dr. Mendoza and colleagues.

All study participants were followed for at least 6 months, with a median of 17 months. Patients who developed decompensation or severe bacterial infections had slightly worse liver function (higher international normalized ratio and lower albumin), lower mean platelet count (117 vs. 179 x 10⁹/L; P < .001) and lower mean CAP (297 vs. 318 dBm; P = .030) than did patients who stayed compensated.

CAP above 220 dB/m was marginally associated with a lower risk of decompensation or severe bacterial infections on univariate analysis, as were elevated Model for End-Stage Liver Disease score, elevated Child Pugh score, low platelet count, low serum albumin, elevated serum bilirubin and increased liver stiffness measurement, LSPS, and portal hypertension risk scores.

Dr. Mendoza and colleagues have no relevant financial disclosures. The study received funding from the Swiss government.

SOURCE: Mendoza Y et al. Clin Gastroenterol Hepatol. 2020. doi: 10.1016/j.cgh.2020.04.018.

Readily available and inexpensive noninvasive tests, when used in combination with liver markers obtained with the extra-large probe, can improve the ability to predict risk for decompensation and other adverse outcomes in obese and overweight patients with compensated advanced chronic liver disease (cACLD), according to study results reported in the upcoming issue of the journal Clinical Gastroenterology and Hepatology.

The retrospective study of 272 obese and overweight patients in Bern, Switzerland, and Montreal with cACLD is the first to fully assess the noninvasive marker of portal hypertension along with using the extra-large probe for controlled attenuation parameter (CAP) to determine risk, wrote Yuly Mendoza, MD, of the University of Bern and colleagues. Decompensation in cACLD carries a higher risk of death. The study noted that portal hypertension is a key driver of progression to decompensation, “and as such, it should be identified as soon as possible and treated as needed.”

“Prediction of prognosis in cACLD is challenging, and noninvasive tests are important tools for clinicians to avoid as much as possible the use of more invasive tests,” wrote Dr. Mendoza and colleagues. Based on the extra-large probe, 76% (n = 206) of study patients had metabolic syndrome, sometimes with other etiologies of liver disease, and 57% (n = 154) had cACLD because of nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH).

Twelve patients had decompensation and five developed severe bacterial infections.

“Readily available noninvasive tests can be used to identify obese or overweight patients with cACLD who are at increased risk for decompensation and severe bacterial infections,” wrote the researchers.

The study noted that obesity is a challenge for noninvasive tests and is a major limitation to liver stiffness measurement on transient elastography using the standard M probe. The XL probe has been specifically designed to overcome this challenge in obese patients, but it hasn’t been evaluated for the prediction of clinical decompensation in obese patients with cACLD.

This study claimed to provide further evidence that liver stiffness measurement in combination with noninvasive tests for liver stiffness measurement, spleen size/platelet count (LSPS), portal hypertension and portal hypertension risk score can help identify patients at risk for clinical decompensation and severe bacterial infections.

The study used average area under the receiving operator curve (AUC) to calculate the ability of the markers to distinguish risk, all with 95% confidence interval: 0.803 for liver stiffness measurement, 0.829 for portal hypertension risk score, and 0.845 for LSPS (P < .001). The markers showed an even better ability to differentiate between patients at risk for developing classical clinical decompensation in follow-up from those not at risk (all 95% CI): 0.848 for liver stiffness measurement, 0.881 for portal hypertension risk score, and 0.890 for LSPS (P < .001).

“The results of the present study validate the use of [extra-large] probe for liver stiffness measurement and CAP to stratify the risk of clinical decompensation and clinically relevant events in overweight/obese patients with cACLD, particularly in case of NAFLD/NASH etiology,” wrote Dr. Mendoza and colleagues.

All study participants were followed for at least 6 months, with a median of 17 months. Patients who developed decompensation or severe bacterial infections had slightly worse liver function (higher international normalized ratio and lower albumin), lower mean platelet count (117 vs. 179 x 10⁹/L; P < .001) and lower mean CAP (297 vs. 318 dBm; P = .030) than did patients who stayed compensated.

CAP above 220 dB/m was marginally associated with a lower risk of decompensation or severe bacterial infections on univariate analysis, as were elevated Model for End-Stage Liver Disease score, elevated Child Pugh score, low platelet count, low serum albumin, elevated serum bilirubin and increased liver stiffness measurement, LSPS, and portal hypertension risk scores.

Dr. Mendoza and colleagues have no relevant financial disclosures. The study received funding from the Swiss government.

SOURCE: Mendoza Y et al. Clin Gastroenterol Hepatol. 2020. doi: 10.1016/j.cgh.2020.04.018.

The Infectious Disease Society of America has released new guidelines on the use and reuse of personal protective equipment, most of which address the use of face protection, for health care workers caring for COVID-19 patients. In releasing the guidelines, the IDSA expert guideline panel acknowledged gaps in evidence to support the recommendations, which is why they will be updated regularly as new evidence emerges.

“Our real goal here is to update these guidelines as a live document,” panel chair John Lynch III, MD, MPH, of the University of Washington, Seattle, said in a press briefing. “Looking at whatever research is coming out where it gets to the point where we find that the evidence is strong enough to make a change, I think we’ll need to readdress these recommendations.”

The panel tailored recommendations to the availability of supplies: conventional capacity for usual supplies; contingency capacity, when supplies are conserved, adapted and substituted with occasional reuse of select supplies; and crisis capacity, when critical supplies are lacking.

The guidelines contain the following eight recommendations for encounters with suspected or confirmed COVID-19 patients:

1) Either a surgical mask or N95 (or N99 or PAPR [powered & supplied air respiratory protection]) respirator for routine patient care in a conventional setting.

2) Either a surgical mask or reprocessed respirator as opposed to no mask for routine care in a contingency or crisis setting.

3) No recommendation on the use of double gloves vs. single gloves.

4) No recommendation on the use of shoe covers for any setting.

5) An N95 (or N99 or PAPR) respirator for aerosol-generating procedures in a conventional setting.

6) A reprocessed N95 respirator as opposed to a surgical mask for aerosol-generating procedures in a contingency or crisis setting.

7) Adding a face shield or surgical mask as a cover for an N95 respirator to allow for extended use during respirator shortages when performing aerosol-generating procedures in a contingency or crisis setting. This recommendation carries a caveat: It assumes correct doffing sequence and hand hygiene before and after taking off the face shield or surgical mask cover.

8) In the same scenario, adding a face shield or surgical mask over the N95 respirator so it can be reused, again assuming the correct sequence for hand hygiene.

The guideline was developed using the GRADE approach – for Grading of Recommendations Assessment, Development, and Evaluation – and a modified methodology for developing rapid recommendations. The levels of evidence supporting each recommendation vary from moderate for the first two to knowledge gap for the third and fourth to very low certainty for the last four.

“You can see that the eight recommendations that were made, a large part of them are really focused on masks, but there are a huge number of other disparate questions that need to be answered where there is really no good evidence basis,” Dr. Lynch said. “If we see any new evidence around that, we can at least provide commentary but I would really hope evidence-based recommendations around some of those interventions.”

Panel member Allison McGeer, MD, FRCPC, of the University of Toronto, explained the lack of evidence supporting infection prevention in hospitals. “In medicine we tend to look at individual patterns and individual patient outcomes,” she said. “When you’re looking at infection prevention, you’re looking at health systems and their outcomes, and it’s much harder to randomize hospitals or a state or a country to one particular policy about how to protect patients from infections in hospitals.”

SOURCE: Lynch JB et al. IDSA. April 27, 2020.

The Infectious Disease Society of America has released new guidelines on the use and reuse of personal protective equipment, most of which address the use of face protection, for health care workers caring for COVID-19 patients. In releasing the guidelines, the IDSA expert guideline panel acknowledged gaps in evidence to support the recommendations, which is why they will be updated regularly as new evidence emerges.

“Our real goal here is to update these guidelines as a live document,” panel chair John Lynch III, MD, MPH, of the University of Washington, Seattle, said in a press briefing. “Looking at whatever research is coming out where it gets to the point where we find that the evidence is strong enough to make a change, I think we’ll need to readdress these recommendations.”

The panel tailored recommendations to the availability of supplies: conventional capacity for usual supplies; contingency capacity, when supplies are conserved, adapted and substituted with occasional reuse of select supplies; and crisis capacity, when critical supplies are lacking.

The guidelines contain the following eight recommendations for encounters with suspected or confirmed COVID-19 patients:

1) Either a surgical mask or N95 (or N99 or PAPR [powered & supplied air respiratory protection]) respirator for routine patient care in a conventional setting.

2) Either a surgical mask or reprocessed respirator as opposed to no mask for routine care in a contingency or crisis setting.

3) No recommendation on the use of double gloves vs. single gloves.

4) No recommendation on the use of shoe covers for any setting.

5) An N95 (or N99 or PAPR) respirator for aerosol-generating procedures in a conventional setting.

6) A reprocessed N95 respirator as opposed to a surgical mask for aerosol-generating procedures in a contingency or crisis setting.

7) Adding a face shield or surgical mask as a cover for an N95 respirator to allow for extended use during respirator shortages when performing aerosol-generating procedures in a contingency or crisis setting. This recommendation carries a caveat: It assumes correct doffing sequence and hand hygiene before and after taking off the face shield or surgical mask cover.

8) In the same scenario, adding a face shield or surgical mask over the N95 respirator so it can be reused, again assuming the correct sequence for hand hygiene.

The guideline was developed using the GRADE approach – for Grading of Recommendations Assessment, Development, and Evaluation – and a modified methodology for developing rapid recommendations. The levels of evidence supporting each recommendation vary from moderate for the first two to knowledge gap for the third and fourth to very low certainty for the last four.

“You can see that the eight recommendations that were made, a large part of them are really focused on masks, but there are a huge number of other disparate questions that need to be answered where there is really no good evidence basis,” Dr. Lynch said. “If we see any new evidence around that, we can at least provide commentary but I would really hope evidence-based recommendations around some of those interventions.”

Panel member Allison McGeer, MD, FRCPC, of the University of Toronto, explained the lack of evidence supporting infection prevention in hospitals. “In medicine we tend to look at individual patterns and individual patient outcomes,” she said. “When you’re looking at infection prevention, you’re looking at health systems and their outcomes, and it’s much harder to randomize hospitals or a state or a country to one particular policy about how to protect patients from infections in hospitals.”

SOURCE: Lynch JB et al. IDSA. April 27, 2020.

The Infectious Disease Society of America has released new guidelines on the use and reuse of personal protective equipment, most of which address the use of face protection, for health care workers caring for COVID-19 patients. In releasing the guidelines, the IDSA expert guideline panel acknowledged gaps in evidence to support the recommendations, which is why they will be updated regularly as new evidence emerges.

“Our real goal here is to update these guidelines as a live document,” panel chair John Lynch III, MD, MPH, of the University of Washington, Seattle, said in a press briefing. “Looking at whatever research is coming out where it gets to the point where we find that the evidence is strong enough to make a change, I think we’ll need to readdress these recommendations.”

The panel tailored recommendations to the availability of supplies: conventional capacity for usual supplies; contingency capacity, when supplies are conserved, adapted and substituted with occasional reuse of select supplies; and crisis capacity, when critical supplies are lacking.

The guidelines contain the following eight recommendations for encounters with suspected or confirmed COVID-19 patients:

1) Either a surgical mask or N95 (or N99 or PAPR [powered & supplied air respiratory protection]) respirator for routine patient care in a conventional setting.

2) Either a surgical mask or reprocessed respirator as opposed to no mask for routine care in a contingency or crisis setting.

3) No recommendation on the use of double gloves vs. single gloves.

4) No recommendation on the use of shoe covers for any setting.

5) An N95 (or N99 or PAPR) respirator for aerosol-generating procedures in a conventional setting.

6) A reprocessed N95 respirator as opposed to a surgical mask for aerosol-generating procedures in a contingency or crisis setting.

7) Adding a face shield or surgical mask as a cover for an N95 respirator to allow for extended use during respirator shortages when performing aerosol-generating procedures in a contingency or crisis setting. This recommendation carries a caveat: It assumes correct doffing sequence and hand hygiene before and after taking off the face shield or surgical mask cover.

8) In the same scenario, adding a face shield or surgical mask over the N95 respirator so it can be reused, again assuming the correct sequence for hand hygiene.

The guideline was developed using the GRADE approach – for Grading of Recommendations Assessment, Development, and Evaluation – and a modified methodology for developing rapid recommendations. The levels of evidence supporting each recommendation vary from moderate for the first two to knowledge gap for the third and fourth to very low certainty for the last four.

“You can see that the eight recommendations that were made, a large part of them are really focused on masks, but there are a huge number of other disparate questions that need to be answered where there is really no good evidence basis,” Dr. Lynch said. “If we see any new evidence around that, we can at least provide commentary but I would really hope evidence-based recommendations around some of those interventions.”

Panel member Allison McGeer, MD, FRCPC, of the University of Toronto, explained the lack of evidence supporting infection prevention in hospitals. “In medicine we tend to look at individual patterns and individual patient outcomes,” she said. “When you’re looking at infection prevention, you’re looking at health systems and their outcomes, and it’s much harder to randomize hospitals or a state or a country to one particular policy about how to protect patients from infections in hospitals.”

SOURCE: Lynch JB et al. IDSA. April 27, 2020.

A far-reaching surveillance initiative was implemented in Shenzhen, China, to isolate and contact trace people suspected of having the COVID-19 coronavirus. This initiative led to faster confirmation of new cases and reduced the window of time during which people were infectious in the community. This potentially reduced the number of new infections that arose from each case, according to a study of patients and contacts over 4 weeks (Lancet Infect Dis. 2020 Apr 27. doi: 10.1016/S1473-3099[20]30287-5).

CDC/John Hierholzer, MD

“The experience of COVID-19 in the city of Shenzhen may demonstrate the huge scale of testing and contact tracing that’s needed to reduce the virus spreading,” said study coauthor Ting Ma, PhD, of Harbin Institute of Technology at Shenzhen.

Dr. Ma acknowledged that some of the measures the program used, such as isolating people outside their homes, may be difficult to impose in other countries, “but we urge governments to consider our findings in the global response to COVID-19.”

The study followed 391 coronavirus cases and 1,286 close contacts identified by the Shenzhen Center for Disease Control and Prevention from Jan. 14 to Feb. 12 this year. The study showed that contact tracing led to confirming new diagnoses within 3.2 days on average vs. 5.5 for symptom-based surveillance, and reduced the time it took to isolate newly infected people by 2 days, from an average of 4.6 to 2.7 days. Eighty-seven people were diagnosed with COVID-19 after they were contact traced and tested. Twenty percent of them had no symptoms, and 29% had no fever. Three deaths occurred in the group during the study period.

The surveillance program was comprehensive and intense. On Jan. 8, the Shenzhen CDC started monitoring travelers from Hubei province, of which Wuhan is the capital, for symptoms of COVID-19. Shenzhen is a city of about 12.5 million people in southeastern China, near Hong Kong, and is about 560 miles south of Wuhan. Over the next 2 weeks, the Shenzhen CDC expanded that surveillance program to all travelers from Hubei regardless of symptoms, along with local hospital patients and people detected by fever screenings at area clinics.

Suspected cases and close contacts underwent nasal-swab testing at 40 different locations in the city. The program identified close contacts through contact tracing, and included anyone who lived in the same dwelling, shared a meal, traveled, or had a social interaction with an index 2 days before symptoms appeared. Casual contacts and some close contacts, such as clinic nurses, who wore masks during the encounters were excluded.

“To achieve similar results, other countries might be able to combine near-universal testing and intensive contact tracing with social distancing and partial lockdowns,” said Dr. Ma. “Although no lockdown measures were introduced in Shenzhen until the end of our study period, Wuhan’s lockdown could have significantly restricted the spread of coronavirus to Shenzhen.”

The researchers noted that children are as susceptible to the virus as are adults, even though their symptoms are not as severe as those of adults. The rate of infection in children 10 and younger was similar to the overall infection rate, 7.4% vs. 6.6%, so the researchers noted that surveillance measures should target them as well.

“This study to me confirms a lot of what we’ve already known,” Aaron E. Glatt, MD, chairman of medicine and an epidemiologist at Mount Sinai South Nassau in Oceanside, N.Y., said in an interview. “It’s an elegant study, but at the same time it sends us a message that we’re at a critical point of time for us to intervene and prevent cases at the very beginning.”

He acknowledged that the Shenzhen effort was intense. “It’s always a resource-intense requirement to do such extensive contact tracing, but that doesn’t mean it shouldn’t be done to the best of your ability to do so,” he said. He was struck by the low relative rate of infection among contacts in the study – around 7%. “There are differences obviously in infection rates in every outbreak,” he said. “Every individual has their own particular infection rate. While we can take ranges and statistical guesses for every individual patient, it could be very high or very low, and that’s most critical to nip it in the bud.”

Lead author Qifang Bi and study coauthors had no financial relationships to disclose.

SOURCE: Bi Q et al. Lancet Infect Dis. 2020 Apr 27. doi: 10.1016/S1473-3099(20)30287-5.

A far-reaching surveillance initiative was implemented in Shenzhen, China, to isolate and contact trace people suspected of having the COVID-19 coronavirus. This initiative led to faster confirmation of new cases and reduced the window of time during which people were infectious in the community. This potentially reduced the number of new infections that arose from each case, according to a study of patients and contacts over 4 weeks (Lancet Infect Dis. 2020 Apr 27. doi: 10.1016/S1473-3099[20]30287-5).

CDC/John Hierholzer, MD

“The experience of COVID-19 in the city of Shenzhen may demonstrate the huge scale of testing and contact tracing that’s needed to reduce the virus spreading,” said study coauthor Ting Ma, PhD, of Harbin Institute of Technology at Shenzhen.

Dr. Ma acknowledged that some of the measures the program used, such as isolating people outside their homes, may be difficult to impose in other countries, “but we urge governments to consider our findings in the global response to COVID-19.”

The study followed 391 coronavirus cases and 1,286 close contacts identified by the Shenzhen Center for Disease Control and Prevention from Jan. 14 to Feb. 12 this year. The study showed that contact tracing led to confirming new diagnoses within 3.2 days on average vs. 5.5 for symptom-based surveillance, and reduced the time it took to isolate newly infected people by 2 days, from an average of 4.6 to 2.7 days. Eighty-seven people were diagnosed with COVID-19 after they were contact traced and tested. Twenty percent of them had no symptoms, and 29% had no fever. Three deaths occurred in the group during the study period.

The surveillance program was comprehensive and intense. On Jan. 8, the Shenzhen CDC started monitoring travelers from Hubei province, of which Wuhan is the capital, for symptoms of COVID-19. Shenzhen is a city of about 12.5 million people in southeastern China, near Hong Kong, and is about 560 miles south of Wuhan. Over the next 2 weeks, the Shenzhen CDC expanded that surveillance program to all travelers from Hubei regardless of symptoms, along with local hospital patients and people detected by fever screenings at area clinics.

Suspected cases and close contacts underwent nasal-swab testing at 40 different locations in the city. The program identified close contacts through contact tracing, and included anyone who lived in the same dwelling, shared a meal, traveled, or had a social interaction with an index 2 days before symptoms appeared. Casual contacts and some close contacts, such as clinic nurses, who wore masks during the encounters were excluded.

“To achieve similar results, other countries might be able to combine near-universal testing and intensive contact tracing with social distancing and partial lockdowns,” said Dr. Ma. “Although no lockdown measures were introduced in Shenzhen until the end of our study period, Wuhan’s lockdown could have significantly restricted the spread of coronavirus to Shenzhen.”

The researchers noted that children are as susceptible to the virus as are adults, even though their symptoms are not as severe as those of adults. The rate of infection in children 10 and younger was similar to the overall infection rate, 7.4% vs. 6.6%, so the researchers noted that surveillance measures should target them as well.

“This study to me confirms a lot of what we’ve already known,” Aaron E. Glatt, MD, chairman of medicine and an epidemiologist at Mount Sinai South Nassau in Oceanside, N.Y., said in an interview. “It’s an elegant study, but at the same time it sends us a message that we’re at a critical point of time for us to intervene and prevent cases at the very beginning.”

He acknowledged that the Shenzhen effort was intense. “It’s always a resource-intense requirement to do such extensive contact tracing, but that doesn’t mean it shouldn’t be done to the best of your ability to do so,” he said. He was struck by the low relative rate of infection among contacts in the study – around 7%. “There are differences obviously in infection rates in every outbreak,” he said. “Every individual has their own particular infection rate. While we can take ranges and statistical guesses for every individual patient, it could be very high or very low, and that’s most critical to nip it in the bud.”

Lead author Qifang Bi and study coauthors had no financial relationships to disclose.

SOURCE: Bi Q et al. Lancet Infect Dis. 2020 Apr 27. doi: 10.1016/S1473-3099(20)30287-5.

A far-reaching surveillance initiative was implemented in Shenzhen, China, to isolate and contact trace people suspected of having the COVID-19 coronavirus. This initiative led to faster confirmation of new cases and reduced the window of time during which people were infectious in the community. This potentially reduced the number of new infections that arose from each case, according to a study of patients and contacts over 4 weeks (Lancet Infect Dis. 2020 Apr 27. doi: 10.1016/S1473-3099[20]30287-5).

CDC/John Hierholzer, MD

“The experience of COVID-19 in the city of Shenzhen may demonstrate the huge scale of testing and contact tracing that’s needed to reduce the virus spreading,” said study coauthor Ting Ma, PhD, of Harbin Institute of Technology at Shenzhen.

Dr. Ma acknowledged that some of the measures the program used, such as isolating people outside their homes, may be difficult to impose in other countries, “but we urge governments to consider our findings in the global response to COVID-19.”

The study followed 391 coronavirus cases and 1,286 close contacts identified by the Shenzhen Center for Disease Control and Prevention from Jan. 14 to Feb. 12 this year. The study showed that contact tracing led to confirming new diagnoses within 3.2 days on average vs. 5.5 for symptom-based surveillance, and reduced the time it took to isolate newly infected people by 2 days, from an average of 4.6 to 2.7 days. Eighty-seven people were diagnosed with COVID-19 after they were contact traced and tested. Twenty percent of them had no symptoms, and 29% had no fever. Three deaths occurred in the group during the study period.

The surveillance program was comprehensive and intense. On Jan. 8, the Shenzhen CDC started monitoring travelers from Hubei province, of which Wuhan is the capital, for symptoms of COVID-19. Shenzhen is a city of about 12.5 million people in southeastern China, near Hong Kong, and is about 560 miles south of Wuhan. Over the next 2 weeks, the Shenzhen CDC expanded that surveillance program to all travelers from Hubei regardless of symptoms, along with local hospital patients and people detected by fever screenings at area clinics.

Suspected cases and close contacts underwent nasal-swab testing at 40 different locations in the city. The program identified close contacts through contact tracing, and included anyone who lived in the same dwelling, shared a meal, traveled, or had a social interaction with an index 2 days before symptoms appeared. Casual contacts and some close contacts, such as clinic nurses, who wore masks during the encounters were excluded.

“To achieve similar results, other countries might be able to combine near-universal testing and intensive contact tracing with social distancing and partial lockdowns,” said Dr. Ma. “Although no lockdown measures were introduced in Shenzhen until the end of our study period, Wuhan’s lockdown could have significantly restricted the spread of coronavirus to Shenzhen.”

The researchers noted that children are as susceptible to the virus as are adults, even though their symptoms are not as severe as those of adults. The rate of infection in children 10 and younger was similar to the overall infection rate, 7.4% vs. 6.6%, so the researchers noted that surveillance measures should target them as well.

“This study to me confirms a lot of what we’ve already known,” Aaron E. Glatt, MD, chairman of medicine and an epidemiologist at Mount Sinai South Nassau in Oceanside, N.Y., said in an interview. “It’s an elegant study, but at the same time it sends us a message that we’re at a critical point of time for us to intervene and prevent cases at the very beginning.”

He acknowledged that the Shenzhen effort was intense. “It’s always a resource-intense requirement to do such extensive contact tracing, but that doesn’t mean it shouldn’t be done to the best of your ability to do so,” he said. He was struck by the low relative rate of infection among contacts in the study – around 7%. “There are differences obviously in infection rates in every outbreak,” he said. “Every individual has their own particular infection rate. While we can take ranges and statistical guesses for every individual patient, it could be very high or very low, and that’s most critical to nip it in the bud.”

Lead author Qifang Bi and study coauthors had no financial relationships to disclose.

SOURCE: Bi Q et al. Lancet Infect Dis. 2020 Apr 27. doi: 10.1016/S1473-3099(20)30287-5.

The monoclonal antibody omalizumab, already approved to treat allergic asthma and urticaria, has been shown to improve symptoms of patients who have chronic rhinosinusitis and nasal polyps (CRSwNP), according to recent research released as an abstract from the American Academy of Allergy, Asthma, and Immunology annual meeting. The AAAAI canceled the meeting and provided abstracts and access to presenters for press coverage.

“When you give this drug to patients who have nasal polyposis and concomitant asthma, you are effectively treating both the upper and lower airway disease components,” Jonathan Corren, MD, of the University of California, Los Angeles, said in an interview. “Typically, people with nasal polyp disease have worse nasal disease than people without asthma. In addition, asthma is also generally worse in patients with nasal polyposis,” he added.

Dr. Corren reported results of a subset of patients with corticosteroid-refractory CRSwNP and comorbid asthma enrolled in phase III, placebo-controlled, 24-week, trials of omalizumab, POLYP1 (n = 74) and POLYP2 (n = 77). The analysis excluded patients who were on oral steroids or high-dose steroid inhaler therapy so the effectiveness of omalizumab could be evaluated without interfering factors, Dr. Corren explained. As a result, the study population consisted of patients with mild to moderate asthma. Dr. Corren is also principal investigator of the POLYP1 trial.

The analysis compared changes in Asthma Quality of Life Questionnaire (AQLQ) and sino-nasal outcome test (SNOT-22) measures after 24 weeks of treatment with those seen with placebo.

“With regard to asthma outcomes, we found there was a significant increase in the odds ratio that patients who received omalizumab would achieve a minimal, clinically important improvement in their asthma quality of life,” Dr. Corren said .

The study estimated the odds ratio for minimal clinically important difference in AQLQ at 24 weeks was 3.9 (95% confidence interval, 1.5-9.7; P = .0043), which Dr. Corren called “quite significant.” SNOT-22 scores showed a mean improvement of 23.3 from baseline to week 24, compared with a worsening of 8.4 in placebo (P = .0001).

Omalizumab is approved for treatment of perennial allergies and urticaria. Chronic rhinosinusitis with nasal polyps would be a third indication if the Food and Drug Administration approves it, Dr. Corren noted.

Genentech sponsored the subset analysis. Hoffmann-La Roche, Genentech’s parent company, is sponsor of the POLYP1 and POLYP2 trials. Dr. Corren disclosed financial relationships with Genentech.

SOURCE: Corren J et al. AAAAI, Session 4608, Abstract 813.

The monoclonal antibody omalizumab, already approved to treat allergic asthma and urticaria, has been shown to improve symptoms of patients who have chronic rhinosinusitis and nasal polyps (CRSwNP), according to recent research released as an abstract from the American Academy of Allergy, Asthma, and Immunology annual meeting. The AAAAI canceled the meeting and provided abstracts and access to presenters for press coverage.

“When you give this drug to patients who have nasal polyposis and concomitant asthma, you are effectively treating both the upper and lower airway disease components,” Jonathan Corren, MD, of the University of California, Los Angeles, said in an interview. “Typically, people with nasal polyp disease have worse nasal disease than people without asthma. In addition, asthma is also generally worse in patients with nasal polyposis,” he added.

Dr. Corren reported results of a subset of patients with corticosteroid-refractory CRSwNP and comorbid asthma enrolled in phase III, placebo-controlled, 24-week, trials of omalizumab, POLYP1 (n = 74) and POLYP2 (n = 77). The analysis excluded patients who were on oral steroids or high-dose steroid inhaler therapy so the effectiveness of omalizumab could be evaluated without interfering factors, Dr. Corren explained. As a result, the study population consisted of patients with mild to moderate asthma. Dr. Corren is also principal investigator of the POLYP1 trial.

The analysis compared changes in Asthma Quality of Life Questionnaire (AQLQ) and sino-nasal outcome test (SNOT-22) measures after 24 weeks of treatment with those seen with placebo.

“With regard to asthma outcomes, we found there was a significant increase in the odds ratio that patients who received omalizumab would achieve a minimal, clinically important improvement in their asthma quality of life,” Dr. Corren said .

The study estimated the odds ratio for minimal clinically important difference in AQLQ at 24 weeks was 3.9 (95% confidence interval, 1.5-9.7; P = .0043), which Dr. Corren called “quite significant.” SNOT-22 scores showed a mean improvement of 23.3 from baseline to week 24, compared with a worsening of 8.4 in placebo (P = .0001).

Omalizumab is approved for treatment of perennial allergies and urticaria. Chronic rhinosinusitis with nasal polyps would be a third indication if the Food and Drug Administration approves it, Dr. Corren noted.

Genentech sponsored the subset analysis. Hoffmann-La Roche, Genentech’s parent company, is sponsor of the POLYP1 and POLYP2 trials. Dr. Corren disclosed financial relationships with Genentech.

SOURCE: Corren J et al. AAAAI, Session 4608, Abstract 813.

The monoclonal antibody omalizumab, already approved to treat allergic asthma and urticaria, has been shown to improve symptoms of patients who have chronic rhinosinusitis and nasal polyps (CRSwNP), according to recent research released as an abstract from the American Academy of Allergy, Asthma, and Immunology annual meeting. The AAAAI canceled the meeting and provided abstracts and access to presenters for press coverage.

“When you give this drug to patients who have nasal polyposis and concomitant asthma, you are effectively treating both the upper and lower airway disease components,” Jonathan Corren, MD, of the University of California, Los Angeles, said in an interview. “Typically, people with nasal polyp disease have worse nasal disease than people without asthma. In addition, asthma is also generally worse in patients with nasal polyposis,” he added.

Dr. Corren reported results of a subset of patients with corticosteroid-refractory CRSwNP and comorbid asthma enrolled in phase III, placebo-controlled, 24-week, trials of omalizumab, POLYP1 (n = 74) and POLYP2 (n = 77). The analysis excluded patients who were on oral steroids or high-dose steroid inhaler therapy so the effectiveness of omalizumab could be evaluated without interfering factors, Dr. Corren explained. As a result, the study population consisted of patients with mild to moderate asthma. Dr. Corren is also principal investigator of the POLYP1 trial.

The analysis compared changes in Asthma Quality of Life Questionnaire (AQLQ) and sino-nasal outcome test (SNOT-22) measures after 24 weeks of treatment with those seen with placebo.

“With regard to asthma outcomes, we found there was a significant increase in the odds ratio that patients who received omalizumab would achieve a minimal, clinically important improvement in their asthma quality of life,” Dr. Corren said .

The study estimated the odds ratio for minimal clinically important difference in AQLQ at 24 weeks was 3.9 (95% confidence interval, 1.5-9.7; P = .0043), which Dr. Corren called “quite significant.” SNOT-22 scores showed a mean improvement of 23.3 from baseline to week 24, compared with a worsening of 8.4 in placebo (P = .0001).

Omalizumab is approved for treatment of perennial allergies and urticaria. Chronic rhinosinusitis with nasal polyps would be a third indication if the Food and Drug Administration approves it, Dr. Corren noted.

Genentech sponsored the subset analysis. Hoffmann-La Roche, Genentech’s parent company, is sponsor of the POLYP1 and POLYP2 trials. Dr. Corren disclosed financial relationships with Genentech.

SOURCE: Corren J et al. AAAAI, Session 4608, Abstract 813.

A large pooled analysis of almost 24,000 women showed women who breastfed had a 24% lower risk of invasive ovarian cancer.

Bonnie Becker/MDedge News

Multiple studies have reported a link between breastfeeding and a reduced risk of ovarian cancer, but other studies have found no such link, and the evidence that the protective effects differ by histologic types has been inconclusive.

“This large study with extensive information on breastfeeding provides epidemiological evidence that breastfeeding, a potentially modifiable factor, may confer significant reduction in ovarian cancer risk, including high-grade serous, the deadliest subtype,” Ana Babic, PhD, of Dana-Farber Cancer Institute and Harvard Medical School, both in Boston, and colleagues reported in JAMA Oncology.

Dr. Babic led the study of a pooled analysis of women from 13 case-control studies participating in the Ovarian Cancer Association Consortium. The study evaluated 9,973 women who had ovarian cancer and 13,843 controls, with a mean age of 57 and 56 years, respectively. The data were collected over 20 years through December 2009. Dr. Babic and colleagues claimed that this is the largest study of breastfeeding and ovarian cancer risk to date.

Besides calculating a lower risk of invasive cancer, the analysis also determined that any breastfeeding was associated with a 28% lower risk of borderline cancers, compared with women who never breastfed. “Among invasive tumors, the association was statistically significant for high-grade serous, endometrioid and clear-cell tumors,” Dr. Babic and colleagues wrote, with 25%, 27% and 22% reduced risk, respectively. The researchers also noted a similar, although not statistically significant, reduced risk for low-grade serous tumors, but no such association for mucinous tumors. For borderline tumors, breastfeeding correlated with a 32% lower risk for mucinous tumors and 23% reduction in risk for serous tumors.

The analysis included five studies with data on exclusive breastfeeding. Women who breastfed exclusively for at least 3 months had a 19% reduced risk of ovarian cancer, compared with women who never breastfed, while women who breastfed albeit not exclusively for 3 months had a 30% reduced risk. The analysis also found an association between longer duration of breastfeeding and reduced risk of invasive ovarian cancer: less than 3 months duration per child was associated with an 18% lower risk, while more than 12 months was associated with a 34% lower risk (P < .001). Other factors that seemed to mitigate risk were older age when breastfeeding and breastfeeding within the previous 10 years.

One of the strengths of the studies is that it separated low-grade and the more common and deadly high-grade serous tumors. While the analysis found similar trends with endometrioid ovarian cancers, it didn’t reach a conclusion about other invasive histotypes because there were fewer cases to evaluate. Because the study population was predominantly white, the researchers acknowledged they could not sufficiently evaluate patterns among blacks, Asian, and other ethnic groups. “The association between breastfeeding and ovarian cancer needs to be investigated in large populations of other races and ethnicities,” Dr. Babic and colleagues added.

Nonetheless, they noted that their results support the World Health Organization recommendations of at least 6 months of exclusive breastfeeding and continued breastfeeding with complementary foods for 2 years or more, even though breastfeeding for less than 3 months is associated with a significant reduction in ovarian cancer risk.

The study is significant because of its “thoughtful approach to addressing potential confounders (parity, age, etc.),” said David Barrington, MD, gynecologic oncology fellow at Ohio State University James Cancer Center in Columbus.

“For general obstetricians and gynecologists, this study provides an additional reason to advocate for breastfeeding,” Dr. Barrington added. “This data should be included in a thorough discussion of the multitudes of benefits breastfeeding provides to both the infant and the mother.”

He added that future studies should evaluate breastfeeding and ovarian cancer risks in a more ethnically diverse population. “Understanding the potential impact of modifiable risk factors for ovarian cancer is paramount to overcoming racial disparities in outcomes,” Dr. Barrington said.

The study was supported by the U.S. National Cancer Institute. Dr. Babic reported grants from the U.S. National Institutes of Health. Some coauthors reported grants from the NIH, the National Health and Medical Research Council of Australia, the Federal Ministry of Education and Research of Germany, the Danish Cancer Society, or the Mermaid I Project. Some coauthors had no disclosures to report. Dr. Barrington has no relevant relationships to disclose.

SOURCE: Babic A et al. JAMA Oncology. 2020. doi: 10.1001/jamaoncol.2020.0421.

A large pooled analysis of almost 24,000 women showed women who breastfed had a 24% lower risk of invasive ovarian cancer.

Bonnie Becker/MDedge News

Multiple studies have reported a link between breastfeeding and a reduced risk of ovarian cancer, but other studies have found no such link, and the evidence that the protective effects differ by histologic types has been inconclusive.

“This large study with extensive information on breastfeeding provides epidemiological evidence that breastfeeding, a potentially modifiable factor, may confer significant reduction in ovarian cancer risk, including high-grade serous, the deadliest subtype,” Ana Babic, PhD, of Dana-Farber Cancer Institute and Harvard Medical School, both in Boston, and colleagues reported in JAMA Oncology.

Dr. Babic led the study of a pooled analysis of women from 13 case-control studies participating in the Ovarian Cancer Association Consortium. The study evaluated 9,973 women who had ovarian cancer and 13,843 controls, with a mean age of 57 and 56 years, respectively. The data were collected over 20 years through December 2009. Dr. Babic and colleagues claimed that this is the largest study of breastfeeding and ovarian cancer risk to date.

Besides calculating a lower risk of invasive cancer, the analysis also determined that any breastfeeding was associated with a 28% lower risk of borderline cancers, compared with women who never breastfed. “Among invasive tumors, the association was statistically significant for high-grade serous, endometrioid and clear-cell tumors,” Dr. Babic and colleagues wrote, with 25%, 27% and 22% reduced risk, respectively. The researchers also noted a similar, although not statistically significant, reduced risk for low-grade serous tumors, but no such association for mucinous tumors. For borderline tumors, breastfeeding correlated with a 32% lower risk for mucinous tumors and 23% reduction in risk for serous tumors.

The analysis included five studies with data on exclusive breastfeeding. Women who breastfed exclusively for at least 3 months had a 19% reduced risk of ovarian cancer, compared with women who never breastfed, while women who breastfed albeit not exclusively for 3 months had a 30% reduced risk. The analysis also found an association between longer duration of breastfeeding and reduced risk of invasive ovarian cancer: less than 3 months duration per child was associated with an 18% lower risk, while more than 12 months was associated with a 34% lower risk (P < .001). Other factors that seemed to mitigate risk were older age when breastfeeding and breastfeeding within the previous 10 years.

One of the strengths of the studies is that it separated low-grade and the more common and deadly high-grade serous tumors. While the analysis found similar trends with endometrioid ovarian cancers, it didn’t reach a conclusion about other invasive histotypes because there were fewer cases to evaluate. Because the study population was predominantly white, the researchers acknowledged they could not sufficiently evaluate patterns among blacks, Asian, and other ethnic groups. “The association between breastfeeding and ovarian cancer needs to be investigated in large populations of other races and ethnicities,” Dr. Babic and colleagues added.

Nonetheless, they noted that their results support the World Health Organization recommendations of at least 6 months of exclusive breastfeeding and continued breastfeeding with complementary foods for 2 years or more, even though breastfeeding for less than 3 months is associated with a significant reduction in ovarian cancer risk.

The study is significant because of its “thoughtful approach to addressing potential confounders (parity, age, etc.),” said David Barrington, MD, gynecologic oncology fellow at Ohio State University James Cancer Center in Columbus.

“For general obstetricians and gynecologists, this study provides an additional reason to advocate for breastfeeding,” Dr. Barrington added. “This data should be included in a thorough discussion of the multitudes of benefits breastfeeding provides to both the infant and the mother.”

He added that future studies should evaluate breastfeeding and ovarian cancer risks in a more ethnically diverse population. “Understanding the potential impact of modifiable risk factors for ovarian cancer is paramount to overcoming racial disparities in outcomes,” Dr. Barrington said.

The study was supported by the U.S. National Cancer Institute. Dr. Babic reported grants from the U.S. National Institutes of Health. Some coauthors reported grants from the NIH, the National Health and Medical Research Council of Australia, the Federal Ministry of Education and Research of Germany, the Danish Cancer Society, or the Mermaid I Project. Some coauthors had no disclosures to report. Dr. Barrington has no relevant relationships to disclose.

SOURCE: Babic A et al. JAMA Oncology. 2020. doi: 10.1001/jamaoncol.2020.0421.

A large pooled analysis of almost 24,000 women showed women who breastfed had a 24% lower risk of invasive ovarian cancer.

Bonnie Becker/MDedge News

Multiple studies have reported a link between breastfeeding and a reduced risk of ovarian cancer, but other studies have found no such link, and the evidence that the protective effects differ by histologic types has been inconclusive.

“This large study with extensive information on breastfeeding provides epidemiological evidence that breastfeeding, a potentially modifiable factor, may confer significant reduction in ovarian cancer risk, including high-grade serous, the deadliest subtype,” Ana Babic, PhD, of Dana-Farber Cancer Institute and Harvard Medical School, both in Boston, and colleagues reported in JAMA Oncology.

Dr. Babic led the study of a pooled analysis of women from 13 case-control studies participating in the Ovarian Cancer Association Consortium. The study evaluated 9,973 women who had ovarian cancer and 13,843 controls, with a mean age of 57 and 56 years, respectively. The data were collected over 20 years through December 2009. Dr. Babic and colleagues claimed that this is the largest study of breastfeeding and ovarian cancer risk to date.

Besides calculating a lower risk of invasive cancer, the analysis also determined that any breastfeeding was associated with a 28% lower risk of borderline cancers, compared with women who never breastfed. “Among invasive tumors, the association was statistically significant for high-grade serous, endometrioid and clear-cell tumors,” Dr. Babic and colleagues wrote, with 25%, 27% and 22% reduced risk, respectively. The researchers also noted a similar, although not statistically significant, reduced risk for low-grade serous tumors, but no such association for mucinous tumors. For borderline tumors, breastfeeding correlated with a 32% lower risk for mucinous tumors and 23% reduction in risk for serous tumors.

The analysis included five studies with data on exclusive breastfeeding. Women who breastfed exclusively for at least 3 months had a 19% reduced risk of ovarian cancer, compared with women who never breastfed, while women who breastfed albeit not exclusively for 3 months had a 30% reduced risk. The analysis also found an association between longer duration of breastfeeding and reduced risk of invasive ovarian cancer: less than 3 months duration per child was associated with an 18% lower risk, while more than 12 months was associated with a 34% lower risk (P < .001). Other factors that seemed to mitigate risk were older age when breastfeeding and breastfeeding within the previous 10 years.

One of the strengths of the studies is that it separated low-grade and the more common and deadly high-grade serous tumors. While the analysis found similar trends with endometrioid ovarian cancers, it didn’t reach a conclusion about other invasive histotypes because there were fewer cases to evaluate. Because the study population was predominantly white, the researchers acknowledged they could not sufficiently evaluate patterns among blacks, Asian, and other ethnic groups. “The association between breastfeeding and ovarian cancer needs to be investigated in large populations of other races and ethnicities,” Dr. Babic and colleagues added.

Nonetheless, they noted that their results support the World Health Organization recommendations of at least 6 months of exclusive breastfeeding and continued breastfeeding with complementary foods for 2 years or more, even though breastfeeding for less than 3 months is associated with a significant reduction in ovarian cancer risk.

The study is significant because of its “thoughtful approach to addressing potential confounders (parity, age, etc.),” said David Barrington, MD, gynecologic oncology fellow at Ohio State University James Cancer Center in Columbus.

“For general obstetricians and gynecologists, this study provides an additional reason to advocate for breastfeeding,” Dr. Barrington added. “This data should be included in a thorough discussion of the multitudes of benefits breastfeeding provides to both the infant and the mother.”

He added that future studies should evaluate breastfeeding and ovarian cancer risks in a more ethnically diverse population. “Understanding the potential impact of modifiable risk factors for ovarian cancer is paramount to overcoming racial disparities in outcomes,” Dr. Barrington said.

The study was supported by the U.S. National Cancer Institute. Dr. Babic reported grants from the U.S. National Institutes of Health. Some coauthors reported grants from the NIH, the National Health and Medical Research Council of Australia, the Federal Ministry of Education and Research of Germany, the Danish Cancer Society, or the Mermaid I Project. Some coauthors had no disclosures to report. Dr. Barrington has no relevant relationships to disclose.

SOURCE: Babic A et al. JAMA Oncology. 2020. doi: 10.1001/jamaoncol.2020.0421.

Maternal preconception exposure to phthalates was associated with increased risk of preterm birth, according to a study of 420 births to subfertile couples over a 13-year period.

Previous studies have shown increased risk of preterm birth associated with prenatal exposure to phthalates, which are commonly found in a range of household and commercial products as well as medical equipment and some pharmaceuticals.

“Our results suggest that female exposure to [4 di(2-ethylhexyl) phthalate] DEHP before conception might be an unrecognized risk factor for adverse pregnancy outcomes, often overlooked in clinical practice,” wrote Yu Zhang of the department of environmental health at Harvard T.H. Chan School of Public Health, Boston, and colleagues.

The prospective cohort study evaluated preconception urinary levels of phthalates and phthalate substitutes in 419 women and 229 men participating in the Environment and Reproductive Health (EARTH) study, a cohort of couples seeking fertility care at the Massachusetts General Hospital Fertility Center. The study cohort gave birth during 2005-2018. The average gestational age of the 420 singleton children born to this cohort was 39 weeks, with 8% (n = 34) born preterm.

Adjusted models showed that maternal preconception urinary concentrations of phthalates and of cyclohexane-1, 2-dicarboxylic acid monohydroxy isononyl ester (MHiNCH), a metabolite of a nonphthalate plasticizer substitute, were associated with a 50% and 70% increased risk of preterm birth, respectively (P = .01, .11), according to results published in JAMA Network Open .

Sensitivity analysis showed that maternal preconception MHiNCH concentrations above the median were associated with a fourfold increased risk of preterm birth (risk ratio, 4.02; P = .08), Maternal preconception MHiNCH concentrations were associated with an average 2-day reduction in gestational age (P = .02).

Covariate-adjusted models found that paternal urinary phthalate metabolite concentrations were associated with an increased risk of preterm birth (RR, 1.41; P = .09), but this association was attenuated toward zero (RR, 1.06) in models that accounted for maternal preconception phthalate concentrations. Sensitivity analysis of 228 couples found the associations of maternal preconception phthalate metabolite concentrations and preterm birth remained robust in three different models: a twofold increased risk in covariate-adjusted models (P < .001); an almost fivefold increased risk in adjusting for prenatal levels (RR, 4.98; P < .001); and a twofold risk (P = .001) in adjusting for paternal levels. “Couple-based analyses confirmed the results for an association between maternal preconception DEHP concentrations and increased risk of preterm birth,” the investigators said.

“To our knowledge, this is the first study evaluating couples’ exposure to phthalate metabolites during the preconception window and its association with preterm birth,” the researchers wrote. “Our findings support a novel hypothesis: Maternal phthalate exposure during the critical period before conception may be associated with shorter gestation.”

“This study is consistent with several, but not all, prior studies supporting maternal prenatal exposure to phthalates increase preterm birth,” said Mark P. Trolice, MD, professor of obstetrics and gynecology at the University of Central Florida, Orlando. “The uniqueness of the current study was the assessment of couples’ exposures and the outcome, though paternal exposure to phthalates did not demonstrate a significant association.”

Dr. Trolice noted that about 25% of women in the study were smokers, but the study didn’t adjust for tobacco use and phthalate exposure, and 85% of the women were white. He urged caution in applying the study results in practice, adding that the study didn’t adjust for method of conception. “Assisted reproductive technology, multiple gestation, and advanced age are all known risk factors for preterm birth,”

The National Institute of Environmental Health Science funded the study. Two study coauthors received grants from the NIEHS, one coauthor received grants from the National Institutes of Health, and one received a grant from the Canadian Institutes of Health Research. No other disclosures were reported. Dr. Trolice has no financial relationships to disclose.

SOURCE: Zhang Y et al. JAMA Network Open. 2020; doi: 10.1001/jamanetworkopen.2020.2159.

Maternal preconception exposure to phthalates was associated with increased risk of preterm birth, according to a study of 420 births to subfertile couples over a 13-year period.

Previous studies have shown increased risk of preterm birth associated with prenatal exposure to phthalates, which are commonly found in a range of household and commercial products as well as medical equipment and some pharmaceuticals.

“Our results suggest that female exposure to [4 di(2-ethylhexyl) phthalate] DEHP before conception might be an unrecognized risk factor for adverse pregnancy outcomes, often overlooked in clinical practice,” wrote Yu Zhang of the department of environmental health at Harvard T.H. Chan School of Public Health, Boston, and colleagues.

The prospective cohort study evaluated preconception urinary levels of phthalates and phthalate substitutes in 419 women and 229 men participating in the Environment and Reproductive Health (EARTH) study, a cohort of couples seeking fertility care at the Massachusetts General Hospital Fertility Center. The study cohort gave birth during 2005-2018. The average gestational age of the 420 singleton children born to this cohort was 39 weeks, with 8% (n = 34) born preterm.

Adjusted models showed that maternal preconception urinary concentrations of phthalates and of cyclohexane-1, 2-dicarboxylic acid monohydroxy isononyl ester (MHiNCH), a metabolite of a nonphthalate plasticizer substitute, were associated with a 50% and 70% increased risk of preterm birth, respectively (P = .01, .11), according to results published in JAMA Network Open .

Sensitivity analysis showed that maternal preconception MHiNCH concentrations above the median were associated with a fourfold increased risk of preterm birth (risk ratio, 4.02; P = .08), Maternal preconception MHiNCH concentrations were associated with an average 2-day reduction in gestational age (P = .02).

Covariate-adjusted models found that paternal urinary phthalate metabolite concentrations were associated with an increased risk of preterm birth (RR, 1.41; P = .09), but this association was attenuated toward zero (RR, 1.06) in models that accounted for maternal preconception phthalate concentrations. Sensitivity analysis of 228 couples found the associations of maternal preconception phthalate metabolite concentrations and preterm birth remained robust in three different models: a twofold increased risk in covariate-adjusted models (P < .001); an almost fivefold increased risk in adjusting for prenatal levels (RR, 4.98; P < .001); and a twofold risk (P = .001) in adjusting for paternal levels. “Couple-based analyses confirmed the results for an association between maternal preconception DEHP concentrations and increased risk of preterm birth,” the investigators said.

“To our knowledge, this is the first study evaluating couples’ exposure to phthalate metabolites during the preconception window and its association with preterm birth,” the researchers wrote. “Our findings support a novel hypothesis: Maternal phthalate exposure during the critical period before conception may be associated with shorter gestation.”

“This study is consistent with several, but not all, prior studies supporting maternal prenatal exposure to phthalates increase preterm birth,” said Mark P. Trolice, MD, professor of obstetrics and gynecology at the University of Central Florida, Orlando. “The uniqueness of the current study was the assessment of couples’ exposures and the outcome, though paternal exposure to phthalates did not demonstrate a significant association.”

Dr. Trolice noted that about 25% of women in the study were smokers, but the study didn’t adjust for tobacco use and phthalate exposure, and 85% of the women were white. He urged caution in applying the study results in practice, adding that the study didn’t adjust for method of conception. “Assisted reproductive technology, multiple gestation, and advanced age are all known risk factors for preterm birth,”

The National Institute of Environmental Health Science funded the study. Two study coauthors received grants from the NIEHS, one coauthor received grants from the National Institutes of Health, and one received a grant from the Canadian Institutes of Health Research. No other disclosures were reported. Dr. Trolice has no financial relationships to disclose.

SOURCE: Zhang Y et al. JAMA Network Open. 2020; doi: 10.1001/jamanetworkopen.2020.2159.

Maternal preconception exposure to phthalates was associated with increased risk of preterm birth, according to a study of 420 births to subfertile couples over a 13-year period.

Previous studies have shown increased risk of preterm birth associated with prenatal exposure to phthalates, which are commonly found in a range of household and commercial products as well as medical equipment and some pharmaceuticals.

“Our results suggest that female exposure to [4 di(2-ethylhexyl) phthalate] DEHP before conception might be an unrecognized risk factor for adverse pregnancy outcomes, often overlooked in clinical practice,” wrote Yu Zhang of the department of environmental health at Harvard T.H. Chan School of Public Health, Boston, and colleagues.

The prospective cohort study evaluated preconception urinary levels of phthalates and phthalate substitutes in 419 women and 229 men participating in the Environment and Reproductive Health (EARTH) study, a cohort of couples seeking fertility care at the Massachusetts General Hospital Fertility Center. The study cohort gave birth during 2005-2018. The average gestational age of the 420 singleton children born to this cohort was 39 weeks, with 8% (n = 34) born preterm.

Adjusted models showed that maternal preconception urinary concentrations of phthalates and of cyclohexane-1, 2-dicarboxylic acid monohydroxy isononyl ester (MHiNCH), a metabolite of a nonphthalate plasticizer substitute, were associated with a 50% and 70% increased risk of preterm birth, respectively (P = .01, .11), according to results published in JAMA Network Open .

Sensitivity analysis showed that maternal preconception MHiNCH concentrations above the median were associated with a fourfold increased risk of preterm birth (risk ratio, 4.02; P = .08), Maternal preconception MHiNCH concentrations were associated with an average 2-day reduction in gestational age (P = .02).

Covariate-adjusted models found that paternal urinary phthalate metabolite concentrations were associated with an increased risk of preterm birth (RR, 1.41; P = .09), but this association was attenuated toward zero (RR, 1.06) in models that accounted for maternal preconception phthalate concentrations. Sensitivity analysis of 228 couples found the associations of maternal preconception phthalate metabolite concentrations and preterm birth remained robust in three different models: a twofold increased risk in covariate-adjusted models (P < .001); an almost fivefold increased risk in adjusting for prenatal levels (RR, 4.98; P < .001); and a twofold risk (P = .001) in adjusting for paternal levels. “Couple-based analyses confirmed the results for an association between maternal preconception DEHP concentrations and increased risk of preterm birth,” the investigators said.

“To our knowledge, this is the first study evaluating couples’ exposure to phthalate metabolites during the preconception window and its association with preterm birth,” the researchers wrote. “Our findings support a novel hypothesis: Maternal phthalate exposure during the critical period before conception may be associated with shorter gestation.”

“This study is consistent with several, but not all, prior studies supporting maternal prenatal exposure to phthalates increase preterm birth,” said Mark P. Trolice, MD, professor of obstetrics and gynecology at the University of Central Florida, Orlando. “The uniqueness of the current study was the assessment of couples’ exposures and the outcome, though paternal exposure to phthalates did not demonstrate a significant association.”

Dr. Trolice noted that about 25% of women in the study were smokers, but the study didn’t adjust for tobacco use and phthalate exposure, and 85% of the women were white. He urged caution in applying the study results in practice, adding that the study didn’t adjust for method of conception. “Assisted reproductive technology, multiple gestation, and advanced age are all known risk factors for preterm birth,”

The National Institute of Environmental Health Science funded the study. Two study coauthors received grants from the NIEHS, one coauthor received grants from the National Institutes of Health, and one received a grant from the Canadian Institutes of Health Research. No other disclosures were reported. Dr. Trolice has no financial relationships to disclose.

SOURCE: Zhang Y et al. JAMA Network Open. 2020; doi: 10.1001/jamanetworkopen.2020.2159.